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Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Gemfibrozil / Statins-Hmg-Coa Reductase
Inhibitors
Attending: ___.
Chief Complaint:
positive blood culture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ woman with a history of CAD, sCHF (EF 40-45%),
CKD IV-V, IDDM, HTN, and pseudomembranous colitis s/p colectomy
with ileostomy was referred to ED for positive blood cx after
recent admission ___ for possible viral gastroenteritis
and shortness of breath possibly ___ aspiration. Blood cultures
drawn ___ grew GPR's today c/w corynebacterium or
propionibacterium species and so patient was referred to ED
where she endorsed possible subjective fevers, denied CP/SOB,
abd pain. While in the ED she had an episode reportedly of leg
weakness and vomiting, she tells me it was not so much weakness
as pain in her L thigh which now persists, this is a new pain
for her. She also says the episode of vomiting was very small,
it happened after getting up after urinating and feeling
lightheaded.Initial Vitals 16:10 0 97.7 62 150/54 18 96%. Labs:
Na 132, K 5.9 (lipemic specimen), hco3 21, BUN 60, Cr 2.9, Glu
204, WBC 7.7 62%N Hgb 10.1. She was given insulin, glucose,
calcium, and 1L NS. repeat K was 5.4 with lactate 1.4, EKG
unchanged from prior, CXR non-acute with enlarged heart and mild
pulm edema. Vitals prior to xfer Today 21:29 0 98.5 71 151/55 20
93% RA with FSG 167.
On the floor, says she had cramping in her L thigh which has
been intermittent over the past few days, now resolving.
Review of Systems:
(+) per HPI
(-) chills, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
CAD,
--___, ___. LAD everolimus eluting stent
DM2 c/b nephropathy
--HbA1C 10.3% in ___
CKD Stage IV ___ HTN, DM)
Pseudomembranous colitis s/p colectomy with ileostomy
h/o severe pneumonia c/b respiratory/cardiac arrest
HTN
MDD
Hypertriglyceridemia
?COPD/Asthma
?Stroke in ___, p/w L facial/arm weakness, worked up at ___
vertigo
anemia
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
================
Vitals - 97.8 185/61, 80, 20, 97%RA
GENERAL: NAD, WD/WN, husband at bedside
___: Oriented to place, ___ but did not know month/date or
season- per husband this is baseline
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ known systolic murmur at apex, no
gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. No epigastric ttp,
stoma is pink with soft brown stool in bag.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, LUE fistula with thrill
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
===============
Vitals: 98.5 98.5 128-153/52-61 ___ 18 90-96% RA
General: Awake, alert, no acute distress
HEENT: NC/AT, MMM, sclera anicteric
Lungs: CTAB; no wheezes, rales, rhonchi
CV: RRR, normal S1/S2, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, ileostomy in place with soft
brown output
GU: No Foley present
Ext: Warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS:
===============
___ 05:40PM BLOOD WBC-7.7 RBC-3.41* Hgb-10.1* Hct-29.1*
MCV-86 MCH-29.7 MCHC-34.7 RDW-15.1 Plt ___
___ 05:40PM BLOOD Neuts-62.8 ___ Monos-7.0 Eos-4.2*
Baso-0.4
___ 05:40PM BLOOD Glucose-204* UreaN-60* Creat-2.9* Na-132*
K-5.9* Cl-107 HCO3-21* AnGap-10
___ 05:40PM BLOOD Lipase-60
___ 05:40PM BLOOD Cortsol-10.3
___ 05:57PM BLOOD Lactate-1.4 K-5.4*
___ 07:30PM URINE Color-Straw Appear-Clear Sp ___
___ 07:30PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 07:30PM URINE RBC-3* WBC-3 Bacteri-FEW Yeast-NONE Epi-2
TransE-<1
PERTINENT LABS:
================
___ 06:02AM BLOOD Ret Aut-3.2
___ 06:55AM BLOOD ALT-45* AST-358* LD(LDH)-818*
___ AlkPhos-85 TotBili-0.3
___ 03:10PM BLOOD ALT-47* AST-309* LD(LDH)-581* AlkPhos-89
TotBili-0.3
___ 06:18AM BLOOD ___
___ 06:09AM BLOOD CK(CPK)-6153*
___ 05:52AM BLOOD CK(CPK)-5373*
___ 05:50AM BLOOD ALT-36 AST-97* CK(CPK)-3496* AlkPhos-81
TotBili-0.4
___ 06:12AM BLOOD CK(CPK)-2050*
___ 06:02AM BLOOD LD(LDH)-228 TotBili-0.4
___ 06:12AM BLOOD proBNP-2571*
___ 06:55AM BLOOD CK-MB-10 MB Indx-0.0 cTropnT-0.02*
___ 03:10PM BLOOD CK-MB-7 cTropnT-0.03*
___ 06:12AM BLOOD calTIBC-299 Hapto-21* Ferritn-112 TRF-230
___ 06:02AM BLOOD Hapto-77
___ 06:55AM BLOOD Triglyc-782*
___ 06:55AM BLOOD Cortsol-25.6*
___ 06:18AM BLOOD CRP-1.3
___ 07:30PM URINE RBC-2 WBC-38* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
DISCHARGE LABS:
===============
___ 06:11AM BLOOD WBC-7.0 RBC-3.33* Hgb-10.0* Hct-29.3*
MCV-88 MCH-30.0 MCHC-34.1 RDW-15.1 Plt ___
___ 06:11AM BLOOD Glucose-185* UreaN-62* Creat-3.7* Na-135
K-4.8 Cl-99 HCO3-21* AnGap-20
___ 06:11AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.0
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood Culture, Routine (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
VIRAL CULTURE (Final ___:
ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT
ANTIBODY..
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
___ CXR: Moderate cardiomegaly with mild edema.
___ CXR: In comparison with the study of ___, there is
again substantial enlargement of the cardiac silhouette with
relatively mild vascular congestion. This discordance the raises
the possibility of pericardial effusion or cardiomyopathy.
Minimal small bilateral pleural effusions with probable
atelectatic changes at the bases.
___ilateral dependent atelectasis. Subtle bilateral
ground-glass opacities may represent mild pulmonary edema. No
evidence of pneumonia. Moderate cardiomegaly. Coronary artery
calcifications. 8 mm splenic hypodensity, likely representing a
cyst or hemangioma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. HydrALAzine 50 mg PO Q8H
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Pravastatin 40 mg PO QPM
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. Sodium Bicarbonate 650 mg PO TID
11. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral Q
Weekly
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
13. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD
14. Humalog ___ 30 Units Breakfast
Humalog ___ 30 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. HydrALAzine 50 mg PO Q8H
6. Humalog ___ 30 Units Breakfast
Humalog ___ 30 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Sodium Bicarbonate 1300 mg PO TID
10. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral Q
Weekly
11. Fish Oil (Omega 3) ___ mg PO BID
RX *docosahexanoic acid-epa [Fish Oil] 120 mg-180 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
RX *docosahexanoic acid-epa [Fish Oil] 120 mg-180 mg 1
capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0
12. Gabapentin 100 mg PO DAILY
RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
13. Ferrous Sulfate 325 mg PO DAILY
14. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral QD
15. Outpatient Lab Work
ICD-9 585.9 Please Chem10 panel including Creatinine and fax
results to:
Name: ___
Location: ___
Address: ___
Phone: ___
Fax: ___
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Rhabdomyolysis
Hypoxia
Adenoviral gastroenteritis
bacteremia
Secondary:
chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with positive blood cultures. Evaluate for
pneumonia.
TECHNIQUE: Frontal and lateral chest radiographs were obtained with the
patient in the upright position.
COMPARISON: Radiographs from ___ and ___.
FINDINGS:
The heart continues to be moderately enlarged with mild edema. No focal
consolidation, pleural effusion or pneumothorax is seen.
IMPRESSION:
Moderate cardiomegaly with mild edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman p/w rhabdomyolysis now with new DOE and O2
requirement s/p significant IVF hydration. // ? pulm edema ? pulm edema
IMPRESSION:
In comparison with the study of ___, there is again substantial
enlargement of the cardiac silhouette with relatively mild vascular
congestion. This discordance the raises the possibility of pericardial
effusion or cardiomyopathy. Minimal small bilateral pleural effusions with
probable atelectatic changes at the bases.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman initially presenting with rhabdomyolysis, now
with ongoing O2 requirement in setting of IVF hydration. Hypoxia not resolving
with diuresis, would like to assess for other etiologies for hypoxia. //
?interstitial lung disease
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: DLP: 480 mGy-cm
COMPARISON: CT torso ___.
FINDINGS:
The thyroid is normal. There is a 1.0 cm right paratracheal lymph node. There
are other prominent but not pathologically enlarged mediastinal lymph nodes.
The axillary lymph nodes are prominent but non pathologically enlarged
bilaterally and contains fatty hilum. Supraclavicular and hilar lymph nodes
are not enlarged. Aorta and pulmonary arteries are normal size. There is
moderate cardiomegaly. Coronary artery calcifications. No pericardial
effusion.
There is no focal consolidation, pleural effusion or pneumothorax. Linear
opacities at the lung bases are most consistent with atelectasis. Subtle
bilateral ground-glass opacities may represent mild pulmonary edema. The
airways are patent to the subsegmental level.
No suspicious bony lesions are identified.
There is an 8 mm hypodensity in the spleen. The remainder of the partially
visualized intra-abdominal organs are unremarkable.
IMPRESSION:
Bilateral dependent atelectasis. Subtle bilateral ground-glass opacities may
represent mild pulmonary edema. No evidence of pneumonia.
Moderate cardiomegaly. Coronary artery calcifications.
8 mm splenic hypodensity, likely representing a cyst or hemangioma.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with HYPERKALEMIA, BACTEREMIA NOS
temperature: 97.7
heartrate: 62.0
resprate: 18.0
o2sat: 96.0
sbp: 150.0
dbp: 54.0
level of pain: 0
level of acuity: 3.0 | ___ ___ speaking woman with a history of CAD, sCHF (EF
40-45%), CKD IV-V, IDDM, HTN, and pseudomembranous colitis s/p
colectomy with ileostomy referred for blood cx drawn ___ with
corynebacterium vs. proprionobacterium, admitted for
hyperkalemia and an episode of vomiting/leg cramps in ED with
continued nausea/vomiting, found to have a CK of 35,000 possibly
related to statin therapy.
#POSITIVE BLOOD CULTURE: The patient was called back after prior
admission for GPR's in single cx c/w propionobacterium or
corynebacterium growing 6 days after culture was drawn. Given
that the patient has no prosthetic valves or devices (only stent
from CABG in ___, was afebrile, and had a normal WBC, it was
thought that this was very likely a skin contaminant. Patient
did have vomiting in the ED and on the floor, however this was
determined to be a viral gastroenteritis. Repeat blood cultures
from ___ were negative.
#RHABDOMYOLYSIS. Patient reported L thigh cramping on admission.
CK 35,000 on admission w/ h/o admissions to ___ in ___ and ___
with similar elevations. At these times it seemed to be linked
to her fibrate/statin therapy, and this was the working
diagnosis on this admission as well. This also explains her
elevated AST/LDH as well as her admission hyperkalemia (also in
the setting of ___. Her hyperkalemia was normalized w/
insulin/gluc/calcium and Kayexalate. Pravastatin was promptly
discontinued, and aggressive IV hydration was begun. When the
patient became hypoxic in the setting of CKD and high volume
load, fluids were d/c'd. By this time, her CK had trended below
3,000, so this was deemed safe.
#HYPOXIA. Likely V/Q mismatch ___ pulmonary edema in the setting
of fluids for rhabdomyolsis. No signs of PNA, no suspicion for
PE, and given CHF and CKD, as well as clinical exam, edema was a
sufficient explanation for the hypoxia. The patient was
relatively refractory to to diuresis and the clinical exam was
never c/f significant volume overload, so other etiologies,
including interstitial disease or a clinically significant
decline in cardiac functionm, were entertained. A CT scan
demonstrated only ground-glass opacities c/f pulm edema, and the
patient's O2 sats improved to baseline prior to discharge.
#ADENOVIRUS GASTROENTERITIS. Patient was recently admitted prior
to this admission for vomiting which resolved that admission and
was thought ___ a viral gastroenteritis. On this admission,
initially thought to be related to rhabdomyolysis and resultant
lyte abnormalities, but viral cultures returned positive for
adenovirus. Remaining stool cx/O+P negative. Norovirus negative.
#PYURIA, BACTERIURIA. In the setting of a fever to ___, a UA
and urine cultures were sent. Pt remained asymptomatic. She was
briefly started on ciprofloxacin, but this was discontinued
given lack of symptoms and absence of recurrent fevers.
#FOOT PAIN. A few days prior to discharge, Ms. ___ began
complaining of b/l burning foot pain. Given her history of
diabetes and the quality of the pain, it was thought that this
was consistent with diabetic neuropathy. Started low dose
gabapentin with symptomatic improvement.
#VAGINAL PRURITUS. A few days prior to discharge, Ms. ___
complained of vaginal pruritus w/o dysuria, hematuria, or
reported discharge. A pelvic exam demonstrated white cervical
discharge concerning for candidiasis. She was treated with a
dose of fluconazole.
#DM2: Fingersticks on this admission were 100s to 200s, so we
continued her 30mg humalog ___ qam and qpm plus sliding scale.
#HTN: On amlodipine, metoprolol, hydralazine. BPs were 140s-160s
this admission, outpt recommendation had been to increase
amlodipine to 10mg so we did uptitrate this med. She remained
asymptomatic - no headache, no chest pain, vision changes -
during this admission.
#CHRONIC ANEMIA: Ms. ___ has a chronic normocytic anemia,
with Hgb ___, concerning for anemia of chronic disease. Epo
levels were elevated.
#CKD IV/V: Patient w/ recently placed left fistula. She
continued her phosphate binder, sodium bicarbonate (increased to
1300mg TID on this admission) and vitamin D. Her Cr did rise
with diuresis in the setting of her pulmonary edema and was 3.7
on discharge, but this is in keeping with previous values in her
chart over the past year.
#CAD: Patient was noted to have a lipemic specimen on admission
labs. Triglycerides were found to be ~700. Unfortunately, she
needed to d/c her statin due to the rhabdomyolsis and had had a
previous similar reaction to fenofibrate. We continued her home
aspirin, started fish oil, and scheduled her for follow up in
Cardiology clinic where she will be evaluated for other
lipid-lowering treatments.
#HFrEF. Per patient, she suffers from baseline SOB when climbing
stairs, does not walk a lot, and spends most of her day in bed.
We continued her home metoprolol, Imdur, and hydralazine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea/vomiting, headaches
Major Surgical or Invasive Procedure:
Tunneled dialysis catheter placement ___
Pan-retinal photocoagulation ___
History of Present Illness:
Pt is ___ M with IDDM c/b diabetic retinopathy, nephropathy
and likely gastroparesis vs. cannabis hyperemesis syndrome who
presents with nausea/vomiting, headaches and blurry vision.
Pt has been admitted multiple times in the last few months with
similar complaints thought to be a combination of cannabis
hyperemesis syndrome vs. diabetic gastroparesis and hypertensive
urgency. He has questionable medication compliance at home and
has left AMA for most of these admissions.
He was last hospitalized ___ for similar complaints. He
was
initially sent to the MICU for BP control as it was initially
thought that his headaches and blurry vision were representative
of hypertensive urgency. However, on further optho eval, it was
felt that his vision changes were due to more chronic changes
associated with diabetic retinopathy and poorly controlled HTN.
This hospitalization was also c/b worsening renal function with
a
Cr that was in the ___ range whereas priors were noted to be
creeping up from 2->4 in the last few months. He was evaluated
by renal who did not feel he necessitated RRT at this time but a
recent note mentioned concern for rapidly progressive
nephropathy
(of note, pt had also been on immunosuppression in the past for
what was felt to be FSGS.) BP meds were titrated this
admission,
however, pt left AMA prior to optimization of BP meds.
On presentation, pt reports that he left from his most recent
admission b/c he felt very anxious and needed to be with family,
especially in light of his birthday tomorrow. He has not been
taking all of his meds given intractable nausea and vomiting at
home. He also reports persistent LUQ pain which is fairly
chronic for him. He also reports severe headache that has been
persistent for the last few weeks and vision changes that have
become more severe for the last 2 weeks as well. States he can
only see outlines of shadows and reports new R eye pain. He
denies CP, SOB, dizziness/lightheadedness, fevers, chills,
cough,
or dysuria.
In the ED, VS initially notable for B P: 206/120 which improved
to 140's/90's with administration of home labetalol and hydral.
Exam notable for visual deficits but CN's otherwise intact.
Labs
notable for Cr: 6.1 (was ___ when pt left AMA.) Hb stable at
7.0.
Pt was was also given reglan and morphine for nausea/pain. Also
given CTX for possible UTI and admitted for further management
of
HTN, ___ on CKD, and symptom control.
ROS: Rest of 10-point ROS reviewed and is negative except as
noted above.
Past Medical History:
Type 1 diabetes
cyclic vomiting with multiple admissions for symptom control
Presumed ___ tear in the setting of gastroparesis flare
PUD
HTN
FSGS
Social History:
___
Family History:
Insulin dependent diabetes in multiple family members
Physical ___:
ADMISSION EXAM:
VITALS: ___ ___ Temp: 98.2 PO BP: 147/90 HR: 88 RR: 16 O2
sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: laying in bed head covered with pillow, appears
uncomfortable
EYES: no scleral icterus, no conjunctival injection, pt reports
being able to see number of fingers with L eye, only outline of
my head with R eye
ENT: MMM, clear OP, normal hearing
NECK: Supple, no appreciable LAD
RESP: CTA b/l, no w/r/r, non-labored breathing
CV: RRR, no m/r/g
GI: Soft, Mildly TTP in LUQ, non-distended, normoactive BS
GU: no foley
EXT: wwp, no edema
SKIN: no lesions, no rashes
NEURO: AOx3, moving all extremities purposefully
PSYCH: normal mood and affect
DISCHARGE EXAM
GENERAL: Alert and in no apparent distress, lying in bed
EYES: Anicteric, noninjected
ENT: Ears and nose without visible erythema, masses, or trauma.
Chest wall: tunneled line without significant erythema or
discharge
CV: RRR systolic murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
SKIN: No rashes or ulcerations noted
EXTR: wwp no edema
NEURO: Alert, interactive, face symmetric, speech fluent
PSYCH: patient upset throughout encounter
Pertinent Results:
PERTINENT LABS:
WBC 6.9-9.0 from ___ -> 10.2 (___) -> 12.4 (___)
Hgb 6.7 - 8.1
Plts 240s-280s
Cre up to 6.6 before HD initiated
Alb 2.3 - 2.7
Hep B nonimmune
Hep C neg
Blood, urine cx ___ neg
IMAGING:
CXR ___
In comparison with the study of ___, the left central
catheter has been
removed. There is an placement of a right hemodialysis catheter
with the tip in the upper right atrium. No evidence of post
procedure pneumothorax.
No acute pneumonia or vascular congestion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Metoclopramide 10 mg PO Q8H
3. NIFEdipine (Extended Release) 120 mg PO QPM
4. Pantoprazole 40 mg PO Q12H
5. Losartan Potassium 50 mg PO DAILY
6. HydrALAZINE 50 mg PO Q6H
7. Labetalol 800 mg PO TID
8. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSUN
9. Glargine 10 Units Bedtime
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Headache
2. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice dailu Disp #*60
Tablet Refills:*0
3. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 1 tablet(s) by mouth three times
daily Disp #*90 Tablet Refills:*0
5. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QSAT
6. Glargine 9 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Humalog 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Atorvastatin 80 mg PO QPM
8. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth nightly Disp #*30 Tablet
Refills:*0
9. Metoclopramide 10 mg PO Q8H
RX *metoclopramide HCl [Reglan] 10 mg 1 tablet by mouth up to
three times daily as needed Disp #*90 Tablet Refills:*0
10. NIFEdipine (Extended Release) 120 mg PO QPM
11. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
End-stage renal disease
Diabetic retinopathy with blindness
HTN
Insulin Dependent Diabetes
Suspected gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with ESRD, needs dialysis// needs TLC for
dialysis
COMPARISON: US of right upper extremity veins
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 30 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2 min, 4 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated
using the introducer of the peel-away sheath supplied. Following this, the
peel-away sheath was placed over the ___ wire through which the catheter was
threaded into the right side of the heart with the tip in the right atrium.
The sheath was then peeled away. The catheter was sutured in place with 0 silk
sutures. Steri-strips were also used to close the venotomy incision site.
Final spot fluoroscopic image demonstrating good alignment of the catheter and
no kinking. The tip is in the right atrium. The catheter was flushed and both
lumens were capped. Sterile dressings were applied. The patient tolerated the
procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing dialysis
catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: renal failure. HD catheter placed, patient pulled on HD catheter,
want to confirm tip is still in the RA.// HD catheter placement Contact
name: ___: ___
IMPRESSION:
In comparison with the study of ___, the left central catheter has been
removed. There is an placement of a right hemodialysis catheter with the tip
in the upper right atrium. No evidence of post procedure pneumothorax.
No acute pneumonia or vascular congestion.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Headache, LUQ abd pain
Diagnosed with Essential (primary) hypertension
temperature: 98.8
heartrate: 92.0
resprate: 18.0
o2sat: 98.0
sbp: 190.0
dbp: 119.0
level of pain: 8
level of acuity: 3.0 | Pt is ___ M with IDDM c/b diabetic retinopathy, nephropathy and
likely gastroparesis who presented with nausea/vomiting,
headaches and blurry vision, ultimately started on HD but with
persistently erratic BPs. Left AMA due to family emergency, but
plans to return to care within ___ hours.
# N/V ___ suspected diabetic gastroparesis
# Malnutrition
Pt with multiple admissions for these symptoms and now presented
with the same. Previously thought to be gastroparesis vs.
cannabis-hyperemesis syndrome but given worsening renal
function, may also represent component of uremia. Symptoms
remained poorly controlled despite aggressive medical therapy
with multiple antiemetics including reglan, as well as HD to
address possibility of uremia. Discharged back on prior home
regimen of reglan, although this can be titrated further when he
returns to care. Would attempt to miminize his overall pill
burden as this is a likely contributing factor.
# ESRD now on HD
Patient with rapid progression of renal failure in recent
months. Worsening renal failure attributed to diabetic
nephropathy and renal vascular disease. Due to concern for
uremia he was started on HD during the admission. He underwent 4
HD sessions. He was started on sevelamer and nephrocaps. As
noted above he left AMA on ___. Fortunately he does have an
outpatient HD spot for next week, so after he returns to care
and other medical issues are optimized, he has an HD spot and
transportation to and from his HD center. As of yet no permanent
access plans. He was given careful instructions for care of his
line while outside of the hospital. Upon his representation
would contact ___ regarding outpatient HD
plans.
# Bilateral proliferative diabetic and hypertensive retinopathy
# Bilateral traction retinal detachment with vitreous hemorrhage
# Severe vision loss R>L
Pt reports progressive blurry vision over the last 2 weeks.
Ophtho was consulted and felt symptoms could be consistent with
resolving vitreous hemorrhage. Seen by retinal team on ___iagnosed with severe diabetic retinopathy and he underwent
panretinal photocoagulation in the R eye. Per ophtho note plan
had also been for photocoagulation of L eye, followed by
bilateral vitrectomies as outpatient. Patient left before these
plans could be confirmed, so would recommend touching base with
Dr. ___ patient ___. Patient very distressed by
his vision loss and motivated to pursue ophtho interventions.
# HTN
Patient with history of poorly controlled hypertension,
presented with SBPs in 200s, which was felt to be related to
pain, vomiting, and medication nonadherence. He was changed from
labetalol to carvedilol for increased adherence and restarted on
losartan, as well as his nifedipine and clonidine patch. Home
hydralazine was held. Initially it appeared his HTN was better
controlled, but in the days prior to discharge his BPs
fluctuated from 120s-210s, often higher in the morning and lower
in the afternoon and evening. He received intermittent
hydralazine PRN. His BP will need to be better controlled before
a safe discharge, particularly considering the immediate risk of
worsening retinopathy and vision loss. Would also consider
inpatient secondary hypertension work-up given his erratic BPs.
# IDDM:
A1C 7.9% ___. Glucose control has been very labile in the past.
___ was consulted and titrated insulin through the admission.
His insulin management was complicated by GI symptoms and poor
PO intake. Toward the end of the admission he was typically
eating minimal food through the day until the evening/night,
when he would eat one or two large meals. His insulin was
adjusted accordingly, and his glucose levels were relatively
well controlled, but only in the setting of relatively poor
nutrition. Upon discharge from his re-admission will need to
determine safe plan for insulin at home given his vision loss.
He has had some help recently from family but does not expect
this long term and wishes to inquire about additional help he
can get at home through his insurance (this was not addressed
prior to his leaving AMA). Of note his current regimen is 9
units lantus daily plus 5 units humalog for meal coverage four
times daily if eating (breakfast, lunch, dinner, second dinner),
plus sliding scale. This dosing was overall reduced from his
prior, which likely related to renal failure and also poor PO
intake.
# Anemia
Hb: 7.0 on admission, has recently been in the 7___s. No e/o
bleeding, likely ___ renal disease. Dropped to 6.7 on ___ s/p
1U pRBC with adequate response. Has not received ESA yet due to
poorly controlled HTN.
#Leukocytosis
WBC normal most of admission but rose just prior to his AMA
discharge. No localizing findings or fevers to suggest an
infection. Will need further work-up if still present when
patient returns to care.
#Circumstance of AMA discharge
Patient's aunt fell ill and patient left on short notice to see
her, but plans to return to ED within ___ hours. No
alternative plans were devised to avoid this. Patient also left
from the last admission for personal reasons with a plan to
return, which he followed through with. He is very concerned
about his vision and also recognizes that HD is critical at this
point and that he needs to return to address these and other
issues. Therefore there was no significant question of his
capacity and overall it seemed likely he would return as
planned.
=======================================
TRANSITIONAL ISSUES:
[ ] continue to titrate nausea regimen for suspected
gastroparesis
[ ] Discuss future access plans/?vein mapping with renal team
[ ] touch base with ___ about HD plans
[ ] touch base with Dr. ___ ophtho plans
[ ] Needs plan for insulin management given vision loss
[ ] Titrate BP regimen and consider secondary work-up
[ ] Continued titration of insulin regimen
[ ] recheck CBC and consider infectious work-up if rising
leukocytosis
[ ] consider hep B immunization as outpatient
[ ] discuss with case management potential home care options
given patient's vision loss
=======================================
>30 minutes in patient care and coordination of discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
1. Chest tube placement - right side for his pneumothorax - d/c
on ___
History of Present Illness:
___ year old M adm s/p fall ___ feet from rope swing. +head
strike, +LOC. Pt was admitted ___ and found to have R sided rib
fractures and R small pneumothorax s/p CT placement. Chest tube
now discharged.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge exam:
Vitals reviewed during discharge exam and WNL
Heart: s1, s2 no m/r/g
Lungs: CTAB
Abdomen: soft, nt, nd. Prior chest tube site healing well, no
erythma or discharge appreciated
Ext: no edema
Pertinent Results:
___ WBC-9.6 RBC-4.37* Hgb-14.1 Hct-41.1 MCV-94 MCH-32.3*
MCHC-34.3 RDW-14.5 Plt ___
___ WBC-7.7 RBC-3.92* Hgb-12.6* Hct-36.5* MCV-93 MCH-32.1*
MCHC-34.5 RDW-14.4 Plt ___
___ ___ PTT-24.8* ___
___ ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ Glucose-87 Lactate-2.9* Na-145 K-4.1 Cl-106 calHCO3-20*
CT head (___)
IMPRESSION:
1. No acute intracranial process.
2. Depressed nasal bone, please correlate for acuity.
CT chest: (___)
IMPRESSION:
1. Right lateral ninth, tenth, and eleventh rib fractures with
associated small right anterior pneumothorax, and air in the
right lateral chest wall. The ninth rib fracture is mildly
displaced, and the tenth and eleventh rib fractures are
nondisplaced.
2. No evidence of solid organ injury in the abdomen or pelvis.
CT C-SPINE W/O CONTRAST (___)
IMPRESSION:
No fracture or traumatic malalignment
CXR ___:
IMPRESSION:
Slight interval increase in the small right pneumothorax.
CRX ___:
IMPRESSION:
No pneumothorax or effusion.
CXR ___:
IMPRESSION:
Status post removal of the right-sided chest tube. There is a 1
cm right
apical lateral pneumothorax without evidence of tension.
Minimal atelectasis at the right lung bases. Unchanged
appearance of the left lung and the heart.
CXR ___
IMPRESSION:
As compared to the previous image, the extent of the known right
pneumothorax is constant. No evidence of tension. Better
apparent than on previous images is a slightly displaced
fracture of the ninth and tenth rib on the right. Normal
appearance of the left lung.
CXR ___
IMPRESSION:
Small right apical pneumothorax, overall unchanged.
Medications on Admission:
not recorded
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
hold for loose stools
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
do NOT drive while taking this medication.
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q3-6H
Disp #*40 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM R rib pain
leave on for 12 hours and then remove for 12 hours
RX *lidocaine-menthol [LidoPatch] 4 %-1 % Apply one patch to the
affected area daily Qam Disp #*30 Patch Refills:*0
4. Baclofen 10 mg PO TID
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*33 Tablet Refills:*0
5. OxyCODONE SR (OxyconTIN) 20 mg PO QAM Duration: 4 Days
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth QAM Disp
#*4 Tablet Refills:*0
6. OxyCODONE SR (OxyconTIN) 10 mg PO QHS Duration: 4 Days
After four days, please take one pill in the morning and one at
night for another week.
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth at bedtime
Disp #*18 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right-sided rib fractures ___, small right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: TRAUMA TORSO
INDICATION: ___ with 20-foot fall, right chest and flank pain. Evaluate for
injury.
TECHNIQUE: Contiguous axial MDCT images of the chest abdomen and pelvis were
obtained following the uneventful administration of 130 cc Omnipaque
intravenous contrast. Coronal and sagittal reformations were performed.
DLP: 1150 mGy-cm.
COMPARISON: None
FINDINGS:
CHEST: The thyroid gland is homogeneous. The great vessels of the neck
enhance normally. The heart is normal in size with no pericardial effusion.
There is no axillary, mediastinal, or hilar lymphadenopathy.
Lungs demonstrate moderate dependent bilateral atelectasis with no focal
consolidation or pleural effusion. There are right lateral ninth, tenth, and
eleventh rib fractures with adjacent subcutaneous gas in the right lateral
chest wall (02:56), and a small right anterior pneumothorax. The ninth rib
fracture is mildly displaced, and the tenth and eleventh rib fractures are
nondisplaced. The esophagus follows a normal course and is normal in caliber.
No thoracic spine fractures are seen.
ABDOMEN: The liver is normal in attenuation with no focal hepatic lesions.
The portal and hepatic veins are patent. Gallbladder is within normal limits,
with no stones. The pancreas is normal in attenuation with no duct dilatation
or stranding. Spleen is normal in size and attenuation. The adrenal glands
are morphologically normal bilaterally. The kidneys enhance and excrete
contrast symmetrically. The distal esophagus, stomach, and small bowel are
normal in caliber. Incidentally noted duodenal diverticulum (2:71). The
appendix is normal. The colon is unobstructed with no evidence of colitis.
There is no free fluid in the abdomen.
PELVIS: No free fluid or lymphadenopathy in the pelvis. The bladder,
prostate, and seminal vesicles are normal.
VESSELS: The abdominal aorta demonstrates mild atherosclerotic calcification,
however no aneurysmal dilatation.
OSSEOUS STRUCTURES: Aside from the aforementioned rib fractures, no osseous
injuries detected. Bilateral pars defects are noted at L5-S1, with no
alignment abnormality. Well corticated densities posterior to the left
ischial tuberosity may represent sequela of prior avulsion injury.
IMPRESSION:
1. Right lateral ninth, tenth, and eleventh rib fractures with associated
small right anterior pneumothorax, and air in the right lateral chest wall.
The ninth rib fracture is mildly displaced, and the tenth and eleventh rib
fractures are nondisplaced.
2. No evidence of solid organ injury in the abdomen or pelvis.
NOTIFICATION: The findings were discussed by Dr. ___ with the trauma
team, in person ___ at 4:38 ___, upon discovery of the findings.
Radiology Report
EXAMINATION: PA and lateral chest radiographs
INDICATION: ___ year old man with PTX // interval eval
COMPARISON: Chest radiograph dated ___. CT chest dated ___.
FINDINGS:
A small right pneumothorax persists and was not clearly seen on the prior
radiograph, suggesting interval increase. No evidence of tension. Platelike
atelectasis in the right lower lung is mild. Left infrahilar atelectasis
persists. No focal consolidation, pleural effusion, or pulmonary edema. The
heart size is normal. Multiple right lateral rib fractures are again noted in
better seen on CT. Nonspecific gaseous distension of the imaged bowel without
pneumoperitoneum.
IMPRESSION:
Slight interval increase in the small right pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with right pneumothorax s/p right pigtail
catheter placement // pneumothorax, pigtail placement pneumothorax,
pigtail placement
COMPARISON: Prior chest radiographs ___ and ___ at 10:55.
IMPRESSION:
Right pneumothorax has almost entirely resolved following insertion of a new
pleural drainage catheter. Moderate right basal atelectasis is stable.
Pneumomediastinum may be present. Left lung is clear aside from mild basal
atelectasis. Heart size is normal.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p fall now s/p R chest tube placement // confirm R chest
tube placement confirm R chest tube placement
COMPARISON: Previous chest radiographs ___, most recently 20:37.
IMPRESSION:
There is minimal if any right pneumothorax, and no pleural effusion, following
insertion of a replacement right apical pleural drainage catheter.
Moderate right basal atelectasis has not yet resolved. Left lung is fully
expanded and clear. Heart size is normal.
Radiology Report
EXAMINATION: Portable AP chest radiograph
INDICATION: ___ s/p fall with R rib fx, interval chest tube placement; assess
for interval change // ___ s/p fall with R rib fx, interval chest tube
placement; assess for interval change. please perform at 0600
COMPARISON: Multiple chest radiographs from ___ before and after placement
of the right chest tube.
FINDINGS:
The right chest tube projects over the upper right hemithorax. No
pneumothorax. The lungs are clear. No focal consolidation or pleural
effusion. Elevation of the right hemidiaphragm persists and may suggest some
volume loss. The heart size is normal. Right lateral rib fractures are
incompletely imaged .
IMPRESSION:
No pneumothorax or effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CT placement for pneumothorax after fall //
eval interval change - chest tube on water seat eval interval change -
chest tube on water seat
COMPARISON: Prior chest radiographs ___.
IMPRESSION:
Left pleural drainage catheter has been withdrawn to the level of the right
third anterior interspace. I cannot be sure it is actually intra thoracic.
Right pneumothorax is tiny. No right pleural effusion. Mild bibasilar
atelectasis, slightly greater on the right, unchanged. Normal
cardiomediastinal and hilar silhouettes.
Radiology Report
EXAMINATION: CHEST (PA, LAT AND OBLIQUES)
INDICATION: ___ year old man s/p fall w pneumothorax s/p CT removal // Please
complete standing end expiratory to eval pneumothorax s/p CT removal
COMPARISON: ___
IMPRESSION:
Status post removal of the right-sided chest tube. There is a 1 cm right
apical lateral pneumothorax without evidence of tension. Minimal atelectasis
at the right lung bases. Unchanged appearance of the left lung and the heart.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p fall w pneumothorax // Please eval inter
change. Complete standing end expiratory
COMPARISON: ___, 22:18
IMPRESSION:
As compared to the previous image, the extent of the known right pneumothorax
is constant. No evidence of tension. Better apparent than on previous images
is a slightly displaced fracture of the ninth and tenth rib on the right.
Normal appearance of the left lung
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p fall w pneumothorax // Please eval interval
change after chest tube removal. Standing end expiratory. Please complete test
at 22pm
COMPARISON: ___, 18:53
IMPRESSION:
As compared to the previous radiograph, there is no substantial change in
appearance of the approximately 1 cm right apical pneumothorax without
evidence of tension.
Radiology Report
EXAMINATION: PA and lateral chest radiograph
INDICATION: ___ year old man w pneumothorax. // Eval interval change Please
standing end expiratory. please complete at 6 am prior to rounds.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The small right apical pneumothorax has not increased in size and is perhaps
minimally decreased from the prior exam. No evidence of tension. The size of
the pneumothorax does not appreciably change with inspiration and expiration.
The lungs are otherwise clear. No focal consolidation, pleural effusion, or
pulmonary edema. The heart is normal in size. The mediastinum is not widened.
Multiple right lateral rib fractures are unchanged.
IMPRESSION:
Small right apical pneumothorax, overall unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ male status post trauma, with pneumothorax.
TECHNIQUE: Portable chest radiograph
COMPARISON: CT of the torso obtained concurrently
FINDINGS:
Aside from bilateral infrahilar opacities likely representing atelectasis,
there is no pleural effusion or focal consolidation. Heart size is within
normal limits given the portable technique. Lung volumes are low. Small
pneumothorax and right lateral rib fractures are better appreciated on the
concurrent CT of the torso.
IMPRESSION:
Traumatic findings of right pneumothorax and right lateral rib fractures are
better seen on the concurrent CT of the torso.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with 20-foot fall, right chest/flank pain.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
Coronal and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
DOSE: DLP: 891 mGy-cm
CTDI: 40 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or large mass. The
ventricles and sulci are normal in size and configuration. Compressed nasal
bone is of unclear chronicity. There is moderate mucosal thickening of the
maxillary sinuses and anterior ethmoid air cells bilaterally. The sphenoid
sinuses, frontal sinuses, and mastoid air cells bilaterally are clear. The
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Depressed nasal bone, please correlate for acuity.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with 20-foot fall
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 750 mGy
DLP: 37 mGy-cm
COMPARISON: None
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal narrowing.
IMPRESSION:
No fracture or traumatic malalignment.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with FX MULT RIBS NOS-CLOSED, TRAUM PNEUMOTHORAX-CLOSE, FALL-1 LEVEL TO OTH NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ year old M adm s/p fall ___ feet from rope
swing. +head strike, +LOC. Pt was admitted ___ and found to have
R sided rib fractures and R small pneumothorax s/p CT placement.
Chest tube now discharged showing a small apical pneumothorax,
constant over the course of two days s/p CT removal.
Patient main issues during this hospitalization involved:
1. Pain: Patient had a significant amount of pain when he was
lying in bed, but no pain when standing or sitting. Several
attempts of medication/doses were attempted in order to improve
his pain. On HD 6 he was discharge home. By the time of
discharge his pain had improved with a combination of Oxycontin,
Dilaudid, Tylenol, Lidocaine patch and Baclofen. Patient was
discharge home with the following pain meds regimen:
- Oxycontin 20 mg am x 4 days
- Oxycontin 10mg am x 4 days -> Then pt instructed to take
Oxycontin 10mg am/pm for a week.
- Dilaudid 2mg Q3-6h PRN for 5 days. Then pt instructed to take
either OTC tylenol or Advil
- Baclofen 10mg TID for 11 days
- Lidocaine patch
2. R side pneumothorax:
Patient had a chest tube placed as he was noted to have a slight
increase of his right side pneumothorax. His chest tube was
initially put on suction with successful improvement of his
pneumothorax. After his chest tube was removed patient was
noticed to have a small apical pneumothorax, that was closely
observed the next couple of days. His pneumothorax was small and
stable and we felt it was safe to discharge patient home w close
follow up.
On HD 6 patient was discharge home. On discharge he was
tolerating a regular diet, pain was under better control w PO
pain meds, we was ambulating w/o difficult, his chest tube
incision was c/d. Patient will follow up with us in clinic in
the next couple of weeks. Dr. ___ patient to
follow up with oour Nurse ___ in a week but
unfortunately she does not have any availability in the next
couple of weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Paxil / hydrochlorothiazide / Lipitor / metoprolol /
Prinivil / fluoxetine
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
1) ___: Pacemaker procedure: Battery at ERI s/p generator
replacement. Lower rate was changed to 75 bpm.
2) ___: TTE: Well-seated, normally functioning bileaflet
mitral valve prosthesis. Mildly depressed global left
ventricular systolic function in the setting of beat-to-beat
variability in LVEF secondary to atrial fibrillation. Severe
tricuspid regurgitation. Compared with the prior study (images
reviewed) of ___, a mild reduction in global left
ventricular systolic function is now appreciated. The right
ventricle was not able to be accurately accessed
History of Present Illness:
___ y/o woman with complicated cardiac history, including CAD s/p
PCI, Afib, sick sinus syndrome s/p PPM, MV replacement, and
severe TR that resulted in significant cardiac ascites
presenting with syncopal event on ___. Patient states that
she had walked to the restroom and had just sat down on the
toilet when she felt like a "sheet was coming over her". She
subsequently woke up on the ground and had bruises on her right
shoulder and wrist. She is unsure of headstrike. She was not
confused when she woke up and noticed that 15 minutes had
passed. No incontinence of urine or tongue biting. She decided
to "sleep it off" and came in today at the request of her son.
She has not experienced any chest pain, HA, palpitations.
She has a chronic SOB which is unchanged. She reports having
difficulty walk ___ a city block and climing stairs that has
been ongoing for the past couple months. She denies any recents
fevers, chills, nausea, vomiting, diarrhea, dizziness.
Patient states she was seen in ___ to have her pacemaker
interrogated and was told battery needed replacement, but has
not had that done due to a change in her cardiologist
Patient also recently increased lasix dose per PCP ___ 100mg qAM
and 80mg qPM. Has not taken for past 3 days in case it may have
led to her fall.
In the ED, initial vitals were: 97.7 65 144/46 18 100% RA
- Labs were significant for:
11.0
5.1 >--< 179
33.7 N:66.9 L:21.3 M:9.6 E:1.2 Bas:0.6 ___: 0.4
137 102 9
--------------< 60
5.2 25 0.8
___: 24.9 PTT: 40.4 INR: 2.3
K:4.5 Glu:49 Lactate:1.0
- Imaging revealed: CT head with no acute intracranial process.
CXR No acute cardiopulmonary process. No significant interval
change.
- The patient was not given any medication.
Cards consult recs: No high rates on interrogation, but PPM at
ERI so will require admission for generator change. Please admit
to ___ under ___. NPO after midnight.
Vitals prior to transfer were: HR 60 137/56 16 97% RA
Upon arrival to the floor patient denies any chest pain, SOB,
lightheadedness, dizziness
Past Medical History:
Rheumatic fever at age ___.
Coronary artery disease status post PCI and stents x2 in ___.
History of diastolic dysfunction with congestive heart failure.
History of mechanical mitral valve replacement in ___.
History of paroxysmal atrial fibrillation s/p cardioversion in
___.
History of anxiety and depression.
Sinus node dysfunction, s/p ___ dual chamber pacemaker.
Dyslipidemia
Hypertension
Social History:
___
Family History:
Mother with diabetes and coronary artery disease.
No FH of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 119/90 65 20 100%RA
Orthostatics: Laying 114/48 68, standing 156/63 65
General: Alert, oriented, very anxious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, firm S1 + S2, no appreciable murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-5.1 RBC-3.80* Hgb-11.0* Hct-33.7*
MCV-89 MCH-28.9 MCHC-32.6 RDW-15.9* RDWSD-51.6* Plt ___
___ 04:00PM BLOOD Neuts-66.9 ___ Monos-9.6 Eos-1.2
Baso-0.6 Im ___ AbsNeut-3.42 AbsLymp-1.09* AbsMono-0.49
AbsEos-0.06 AbsBaso-0.03
___ 04:00PM BLOOD Plt ___
___ 04:07PM BLOOD ___ PTT-40.4* ___
___ 04:00PM BLOOD Glucose-60* UreaN-9 Creat-0.8 Na-137
K-5.2* Cl-102 HCO3-25 AnGap-15
___ 04:09PM BLOOD Glucose-49* Lactate-1.0 K-4.5
DISCHARGE LABS:
PERTINENT LABS:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 1 mg PO BID:PRN anxiety
2. Metoprolol Tartrate 50 mg PO DAILY
3. Dofetilide 250 mcg PO Q12H
4. Warfarin 5 mg PO DAILY16
5. Rosuvastatin Calcium 40 mg PO QPM
6. Ferrous Sulfate 325 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN sob
9. Vitamin D 1000 UNIT PO DAILY
10. Furosemide 100 mg PO QAM
11. Furosemide 80 mg PO QHS
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN sob
2. Ferrous Sulfate 325 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. Spironolactone 25 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Lorazepam 1 mg PO BID:PRN anxiety
7. Furosemide 100 mg PO QAM
8. Furosemide 80 mg PO QHS
9. Warfarin 3 mg PO DAILY16
RX *warfarin 2 mg 1.5 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
11. Cephalexin 500 mg PO BID Duration: 3 Days
Take one dose tonight; continue taking one pill twice a day,
your last day will be ___.
RX *cephalexin 500 mg 1 capsule(s) by mouth twice a day Disp #*7
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
Sick Sinus Syndrome s/p PPM
Cardiac Arrest secondary to Torsade
Syncope
Atrial Fibrillation
Secondary Diagnoses:
Diastolic Congestive Heart Failure
Anxiety
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ PMH mitral valve replacement and pacemaker presents
w Fall on ___ // Acute cardiopulmonary change
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Left-sided pacer device is stable in position. The cardiac silhouette remains
mildly enlarged. Mediastinal contours are stable unremarkable. No focal
consolidation is seen. There is no pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process. No significant interval change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ female on Coumadin with a fall on ___. Evaluate
for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformats were also
performed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 14.0 s, 14.2 cm; CTDIvol = 55.1 mGy (Head) DLP =
780.4 mGy-cm.
Total DLP (Head) = 780 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline shift, mass
effect, or acute large vascular territorial infarct. . Mildly prominent
ventricles and sulci are likely secondary to involutional changes.
No acute fracture is seen. The paranasal sinuses and middle ear cavities are
clear. Chronic partial opacification of the right mastoid air cells is noted,
and the left mastoid air cells are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with PPM s/p generator change and attempted RV
lead placement. // Rule out PTX Contact name: ___: ___
Rule out PTX
IMPRESSION:
In comparison with the study of ___, there is little overall change in the
appearance of the dual-channel pacer and leads. Specifically, there is no
evidence of pneumothorax.
No pneumonia or vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, arrhythmia // Please evaluate for
pulmonary edema
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. Moderate
cardiomegaly with mild elongation of the descending aorta. Left pectoral
Port-A-Cath. No pleural effusions. No pneumonia, no pulmonary edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Syncope, Lightheaded
Diagnosed with SYNCOPE AND COLLAPSE
temperature: 97.7
heartrate: 65.0
resprate: 18.0
o2sat: 100.0
sbp: 144.0
dbp: 46.0
level of pain: 0
level of acuity: 2.0 | ___ y/o woman with hx of CAD s/p PCI, Afib, sick sinus syndrome
s/p PPM, MV replacement, and severe TR c/b cardiac ascites
presented with syncopal event. Etiology of her syncope is
unclear; her pacemaker was interrogated and did not show any
arrhythmias at home. It was found that the pacemaker had a low
battery, so she went for generator change with metronic sensia
dual chamber on ___. They tried to place a new RV lead but she
had subclavian vein stenosis that prohibited new lead placement.
Her hospital course c/b torsades leading to vfib cardiac arrest
s/p x1 shock w/ROSC. The torsades was due to long QTC ___
medication error with extra dosing of her dofetilide. She was
transferred to the ICU for close monitoring. Her dofetilide was
held and she was started on metoprolol 50mg BID to control her
atrial fibrillation. Echo showed stable cardiac function. Her
INR was elevated at discharge to 4.7; she will have ___ monitor
her INR closely after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Open right distal radioulnar joint dislocation, right distal
radius fracture
Major Surgical or Invasive Procedure:
___: I&D, ORIF radius, DRUJ pinning ___, ___.
History of Present Illness:
___ year old female w/ PMHx including Alzheimer's dementia and
HLD, RHD, unwitnessed fall possibly down stairs, walked to
family
holding her right arm with bone exposed. C/o some pain to left
forearm. Poor historian given dementia, no other complaints and
history obtained from family. At baseline she is mobile on her
own, knows her close family, can feed herself (right hand),
needs
help getting dressed.
Past Medical History:
Alzheimers
HLD
RHD
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD, A&Ox1, lying on stretcher.
HEENT: Normocephalic.
CV: RRR
RUE: volar splint in place. right upper ext dressing c/d/i.
fingers wwp, cap refill < 2 sec, makes a fist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. Sertraline 10 mg PO DAILY
4. Memantine 10 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, HA, T>100 degrees
2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Partial fill ok. Wean. No driving/heavy machinery.
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed Disp #*25 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Memantine 10 mg PO BID
5. Pravastatin 40 mg PO QPM
6. Sertraline 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right open distal radius fracture and ulnar dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with right arm open compound fracture s/p fall.//
Fracture? Dislocation? Bleed?
TECHNIQUE: CHEST (SINGLE VIEW)
COMPARISON: None.
FINDINGS:
Portable AP view of the chest.
No grossly displaced rib fractures identified. Apparent discontinuity of a
left posterior lower rib is favored to represent overlapping structures.
Scoliotic spine.
The lungs are well expanded and clear. Cardiomediastinal silhouette, hilar
contours, and pleural surfaces are normal.
IMPRESSION:
No grossly displaced rib fractures are identified.
Radiology Report
EXAMINATION: DX FOREARM AND WRIST
INDICATION: History: ___ with right arm open compound fracture s/p fall.//
Fracture? Dislocation? Bleed?
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the right wrist.
COMPARISON: None.
FINDINGS:
There is an open fracture dislocation of the wrist with comminuted,
intra-articular fractures of the distal radial metaphysis/epiphysis, and ulnar
styloid process, and complete volar and radial displacement of the hand and
distal radial fracture fragment. The carpal arcs are relatively preserved.
There is chondrocalcinosis and a type 2 lunate. There are moderate to severe
degenerative changes of the basal joints of the thumb. There is mild cortical
irregularity of the radial head, and a nondisplaced fracture is difficult
exclude on this nondedicated study.
IMPRESSION:
Open fracture dislocation of the right wrist, with complete volar and radial
displacement of the hand and distal radial fragment. Fracture of the ulnar
styloid process.
Mild cortical irregularity of the radial head, suboptimally evaluated. If
there is clinical concern for radial head fracture recommend dedicated elbow
radiographs.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with right arm open compound fracture s/p fall.//
Fracture? Dislocation? Bleed?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.7 cm; CTDIvol = 48.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are normal.
IMPRESSION:
Atrophy.
Otherwise normal study.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with right arm open compound fracture s/p fall.//
Fracture? Dislocation? Bleed?
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.2 s, 20.5 cm; CTDIvol = 22.9 mGy (Body) DLP = 469.2
mGy-cm.
Total DLP (Body) = 469 mGy-cm.
COMPARISON: None.
FINDINGS:
Diffuse osteopenia limits evaluation. No fractures are identified. Alignment
is normal. There is no prevertebral edema. There are multilevel degenerative
changes.
At C2-3 intervertebral osteophytes mildly encroach on the spinal canal. Facet
and uncovertebral osteophytes produce moderate bilateral neural foraminal
narrowing.
At C3-4, intervertebral osteophytes mildly encroach on the spinal canal.
Facet and uncovertebral osteophytes produce moderate left and severe right
neural foraminal narrowing.
At C4-5, intervertebral osteophytes encroach on the spinal canal and may
contact the spinal cord. Facet and uncovertebral osteophytes produce severe
right and moderate left neural foraminal narrowing.
At C5-6, intervertebral osteophytes encroach on the spinal canal and likely
deform the spinal cord. Facet and uncovertebral osteophytes produce severe
right and moderate left neural foraminal narrowing.
At C6-7, intervertebral osteophytes encroach on the spinal canal and may
contact the spinal cord. The facet and uncovertebral osteophytes produce
moderate bilateral neural foraminal narrowing.
There is no spinal canal or neural foraminal narrowing at C7-T1 or the
included portions of the upper thoracic spine.
The thyroid and included lung apices appear.
IMPRESSION:
1. Diffuse osteopenia limits evaluation for subtle fractures.
2. No evidence of fracture or subluxation.
3. Multilevel degenerative disease with spinal canal and neural foraminal
narrowing.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Oth intartic fx lower end r radius, init for opn fx type I/2, Fall on same level, unspecified, initial encounter
temperature: 96.0
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 172.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have an open right distal radius fracture as well as radial
ulnar joint dislocation and was admitted to the hand surgery
service. The patient was taken to the operating room on ___
for irrigation and debridement of the right wrist as well as
operative fixation, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with OT who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right upper extremity. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
afferent loop obstruction
abdominal pain
Major Surgical or Invasive Procedure:
___, PLACEMENT OF JEJUNOSTOMY
History of Present Illness:
ACS Consult H&P ___
Hx obtained from chart, daughter (who translated), and Ms.
___.
HPI: ___ is a ___ w/ hx of total gastrectomy w/ RNY
esophagojejunostomy, D2 lymphadenectomy, and Witzel jejunostomy
(since removed) ___ for T2aN0 gastric adenoCA who is
presenting here to the ED for a <1 day hx of acute onset lower
abd pain i/s/o a ~1 wk hx of intermittent epigastric pain. She
has had similar sx before, being hospitalized for pancreatitis
___. She also had a remote hospitalization in ___ for
SBO
(?closed loop obstruction) that was managed non-operatively.
Yesterday she also noted some nausea, no vomiting. She is
continuing to have BMs and is passing gas. She denies f/c/s,
lightheadedness and/or dizziness, chest pain, SOB, blurry
vision,
h/a's, change in BMs, BRBPR, melena, difficulty urinating,
myalgias, arthralgias, or skin changes; ROS is o/w -ve except as
noted before. A CT A/P was obtained which showed dilated small
bowel thought to be from the biliary limb, c/f afferent loop
obstruction, for which we were consulted.
Past Medical History:
HTN
T2aN0 adenocarcinoma s/p total gastrectomy ___
migraines
vertigo
OA
multinodular goiter
pancreatitis ___
macrocytic anemia
PSHx:
total gastrectomy w/ RNY esophagojejunostomy and D2
lymphadenectomy ___
diagnostic lap ___, RFA of L GSV ___
Social History:
___
Family History:
Mother with thyroid disease, early MI
Physical Exam:
Admission PEx:
VS - 97.8 67 139/63 16 100% RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress, satting
Abd - soft, mild to mod distension, mild
periumbilical/epigastric
ttp w/ no guardine or rebound
MSK & extremities/skin - no leg swelling observed b/l
Discharge PEx:
VS - 97.8 67 139/63 16 100% RA
Gen - NAD
CV - RRR
Pulm - non-labored breathing, no resp distress, satting
Abd - soft, nodistended, J tube in place
MSK & extremities/skin - no leg swelling observed b/l
Pertinent Results:
Admission Labs:
___ 11:00PM BLOOD WBC-7.9 RBC-2.74* Hgb-9.4* Hct-30.5*
MCV-111* MCH-34.3* MCHC-30.8* RDW-21.2* RDWSD-86.4* Plt ___
___ 11:00PM BLOOD Plt ___
___ 06:18AM BLOOD ___ PTT-28.8 ___
___ 11:00PM BLOOD Glucose-116* UreaN-19 Creat-0.7 Na-142
K-5.0 Cl-106 HCO3-23 AnGap-13
___ 11:00PM BLOOD ALT-19 AST-23 AlkPhos-72 TotBili-0.7
___ 11:00PM BLOOD Lipase-834*
___ 11:00PM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.4*
___ 12:52AM BLOOD Lactate-1.1
Discharge Labs:
Imaging:
CT A/P ___
1. Findings concerning for small bowel obstruction, potentially
of the
afferent limb near the jejunojejunostomy, although no definite
transition
point is identified. No obvious evidence of ischemia or
perforation within
the limitations of paucity of intra-abdominal fat. Surgical
consultation
recommended. Additionally, small-bowel follow-through series
with
Gastrografin may be obtained for further assessment.
2. Slight increase in mild-to-moderate intrahepatic biliary
ductal dilatation,
which is nonspecific, could further suggest afferent limb
obstruction.
CT Head ___
1. Small posterior falx subdural hematoma extending to the
tentorium and
adjacent small subarachnoid hemorrhage.
2. Large right occipital parietal scalp hematoma without
fracture.
CXR ___
Hyperinflated lungs compatible with emphysema with no acute
cardiopulmonary process.
CT Head No Contrast ___
Interval increase in size of a posterior falx subdural hematoma
extending to the tentorium and now the anterior falx. There has
been interval increase in the degree of posterior left parietal
subarachnoid hemorrhage as well as new left frontal lobe and
possibly posterior right parietal lobe subarachnoid hemorrhage.
No midline shift.
CT Head No Contrast ___
1. Prominent subdural hemorrhage along the superior falx and
left tentorial leaflet and multiple areas of subarachnoid
hemorrhage involving in the left frontal and temporal lobes are
not significantly changed.
2. Several areas of subarachnoid hemorrhage in the right frontal
and temporal lobes are new or increased in prominence.
CT Head No Contrast ___
1. No evidence of infarction or new intracranial hemorrhage.
2. Redemonstration of prominent subdural hemorrhage along the
superior falx and left tentorial membrane, minimally decreased
in size compared to prior study.
3. Several areas of subarachnoid hemorrhage in the bilateral
frontal and
temporal lobes appear slightly less conspicuous than on prior
study.
4. Large right parietal subgaleal hematoma appears significantly
increased in size compared to prior study, now measuring up to
1.6 cm.
Hip XR ___
No comparison. A pelvis over view as well as 2 projections of
the left hip are provided. Moderate degenerative changes at the
level of both hip joints. No evidence of fracture. Multiple
phleboliths project over the pelvis. Mild degenerative changes
at the level of the sacroiliac joints.
US Abd Limited ___
5.0 x 1.2 x 2.1 cm collection deep to the inferior aspect of the
midline
laparotomy site, differential diagnosis includes hematoma or a
complex seroma.
Unilat Lower Ext Veins ___
Moderate to severe soft tissue swelling overlying the right
posterior knee.
No evidence of deep venous thrombosis in the right lower
extremity veins.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
18" CHROME GRAB BAR - 18" chrome grab bar . use for safety as
directed daily as needed dx: R26.81
18INCH CHROME GRAB BAR - 18inch chrome grab bar . use as
instructed daily Dx:
ADULT BRIEFS- SMALL - adult briefs- small . use ___ and prn for
incontinence
BEDSIDE COMMODE - bedside commode . unsteady gait 781.2
DEXAMETHASONE - dexamethasone 1.5 mg tablet. 1 tablet(s) by
mouth
daily
LORAZEPAM - lorazepam 0.5 mg tablet. TAKE 1 TABLET BY MOUTH AT
BEDTIME AS NEEDED FOR ANXIETY
MECLIZINE - meclizine 12.5 mg tablet. TAKE 1 TABLET BY MOUTH TWO
TIMES A DAY AS ___ OR USE MACHINERY WORK WHILE
ON
MEDS
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1
CAPSULE(S) BY MOUTH DAILY
SHOWER BENCH - shower bench . use when showering/bathing daily
as needed
VERAPAMIL - verapamil 40 mg tablet. 1 and ___ tablet(s) by
mouth
daily
Medications - OTC
ACETAMINOPHEN [CHILDREN\'S PAIN-FEVER RELIEF] - Children\'s Pain
and Fever Relief 160 mg/5 mL oral liquid. TAKE 4 TEASPOONS BY
MOUTH EVERY 6 HOURS FOR PAIN
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Vitamin B-12 500
mcg tablet. 1 TABLET(S) BY MOUTH DAILY
DEXTRAN 70-HYPROMELLOSE [ARTIFICIAL ___ -
Artificial Tears (dextran 70-hypromellose) eye drops. ONE DROP
___. free tears/gel. Let warm water fall on CLOSED
lids for 2 mins in shower. Massage edges of lids/lashes for 30
secs.
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
TABLET(S) BY MOUTH DAILY
FOOD SUPPLEMT, LACTOSE-REDUCED [ENSURE] - Ensure oral liquid. 1
to 2 cans by mouth daily vanilla flavor dx: weight loss
MULTIVITAMIN [DAILY-VITE] - Daily-Vite tablet. 1 TABLET(S) BY
MOUTH DAILT
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
2. Verapamil 60 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
afferent loop obstruction
abdominal pain
subarachnoid hemorrhage
subdural hemorrhage
traumatic brain injury
Discharge Condition:
Clear and coherent
Followup Instructions:
___
Radiology Report
INDICATION: NO_PO contrast; History: ___ with R and L lower quad abd pn NO_PO
contrast// ? appendicitis ? diverticulitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 4.8 s, 38.1 cm; CTDIvol = 7.8 mGy (Body) DLP = 297.9
mGy-cm.
Total DLP (Body) = 308 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
As with prior studies, exam is moderately limited secondary to paucity of
intra-abdominal fat, limiting the potential visualization of inflammatory
changes.
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Again seen are multiple subcentimeter hypodensities throughout
the liver, similar in appearance to the prior study, and likely representing
simple cyst. The liver otherwise demonstrates homogenous attenuation
throughout. Mild-to-moderate intrahepatic biliary ductal dilatation appears
slightly worse than the prior study, especially within the more superior
segments. There is stable extrahepatic biliary dilatation measuring 1.2 cm
(02:18). The gallbladder appears distended with a mild amount of surrounding
free fluid, similar to prior. No gallstones identified.
PANCREAS: The pancreas is not well seen, but has normal attenuation
throughout, without evidence of focal lesions or pancreatic ductal dilatation.
There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Few subcentimeter hypodensities throughout the bilateral kidneys are too small
to characterize but likely represent cysts. There is no evidence of focal
renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The patient is status post total gastrectomy and Roux-en-Y
esophagojejunostomy. There are moderately distended loops of jejunum in the
left mid abdomen to pelvis which contain fecalized material and measure up to
4.9 cm (601:18). This loop of bowel appears to represent the afferent limb,
although it is unclear. Potential transition point is seen near the
jejunojejunal anastomosis. No obvious abnormal wall enhancement. No free
air. Evaluation for mesenteric free fluid limited by body habitus. The colon
and rectum mildly decompressed but contain fecal material and air. The
appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Grade 1 anterolisthesis of L4 on L5 is grossly unchanged.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Findings concerning for small bowel obstruction, potentially of the
afferent limb near the jejunojejunostomy, although no definite transition
point is identified. No obvious evidence of ischemia or perforation within
the limitations of paucity of intra-abdominal fat. Surgical consultation
recommended. Additionally, small-bowel follow-through series with
Gastrografin may be obtained for further assessment.
2. Slight increase in mild-to-moderate intrahepatic biliary ductal dilatation,
which is nonspecific, could further suggest afferent limb obstruction.
RECOMMENDATION(S): Recommend small-bowel follow-through series with
Gastrografin for further assessment.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 2:49 am, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old ___ speaking woman with afferent loop syndrome
with plan to go to operating room tomorrow// pre-operative assessment Surg:
___ (ex-lap, ?SBR)
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT dated ___
FINDINGS:
The lungs are hyperinflated compatible with emphysema. No lobar
consolidation.
Cardiomediastinal silhouette is within normal range.
No pleural effusions or pneumothorax.
Likely calcified right hilar lymph node.
Degenerative changes of the thoracic spine seen.
IMPRESSION:
Hyperinflated lungs compatible with emphysema with no acute cardiopulmonary
process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with afferent limb syndrome who fell getting
out of bed with headstrike// ?hematoma other other pathology secondary to a
fall with headstrike
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is hyperdensity along the posterior falx extending to the left tentorial
leaflet. There is a focus of subarachnoid hemorrhage in the left occipital
parietal region. There is no evidence of acute large territory infarction,
edema,or mass. There is prominence of the ventricles and sulci suggestive of
involutional changes.
There is a large right occipital parietal scalp hematoma and overlying
laceration. There is no evidence of fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Small posterior falx subdural hematoma extending to the tentorium and
adjacent small subarachnoid hemorrhage.
2. Large right occipital parietal scalp hematoma without fracture.
NOTIFICATION: Discussed with night resident who accompanied the patient to
the ED.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman s/p fall with SDH and IPHPlease perform at
10am// interval change in SDH and IPH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Prior head CT dated ___ 01:55
FINDINGS:
In comparison to prior exam there has been significant interval accumulation
of hyperdense blood products along the posterior falx extending along the left
tentorial leaflet. Blood is seen to involve the anterior falx as well. A
focus subarachnoid hemorrhage in the left occipital parietal region is
increased from prior. There is new subarachnoid hemorrhage involving the
posterior left parietal lobe and overlying the left frontal lobe (03:20).
There is a suggestion of foci of subarachnoid blood in the posterior right
parietal lobe (03:19). There is no acute large territorial infarction. The
ventricles and sulci are otherwise unchanged in appearance. There is no
midline shift. Basal cisterns appear patent.
A right occipital parietal scalp hematoma is similar appearance to the prior.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
Interval increase in size of a posterior falx subdural hematoma extending to
the tentorium and now the anterior falx. There has been interval increase in
the degree of posterior left parietal subarachnoid hemorrhage as well as new
left frontal lobe and possibly posterior right parietal lobe subarachnoid
hemorrhage. No midline shift.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:41 am, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with traumatic brain injury s/p fall with head
strike// please evaluate for interval change in ___ and ___
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
Prominent subdural hemorrhage along the superior falx and left tentorial
leaflet is not significantly changed. Several areas of subarachnoid
hemorrhage in the right frontal and temporal lobes are new or increased in
prominence. Multiple areas subarachnoid hemorrhage are again seen involving
the left frontal and temporal lobes.
There is no evidence of acute large territorial ischemic infarction or mass
effect. There is prominence of the ventricles and sulci suggestive of
atrophy.
There is no evidence of acute fracture. The visualized portion of the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. A right occipital scalp
hematoma is smaller.
IMPRESSION:
1. Prominent subdural hemorrhage along the superior falx and left tentorial
leaflet and multiple areas of subarachnoid hemorrhage involving in the left
frontal and temporal lobes are not significantly changed.
2. Several areas of subarachnoid hemorrhage in the right frontal and temporal
lobes are new or increased in prominence.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:15 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with hx total gastrectomy RNY esophagoJ ___ for gastric
adenoCA p/w 1 wk abd pain CT c/f afferent loop obs c/b inpt fall ___ s/p
___ enteroenterostomy, feeding J-tube placement, chest now fell and hit
head. Evaluation for interval change, acute hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Comparison to noncontrast head CT from ___.
FINDINGS:
Redemonstration of prominent subdural hemorrhage along the superior falx and
left tentorium, minimally decreased in size compared to prior study. Several
areas of subarachnoid hemorrhage in the bilateral frontal and temporal lobes
appear slightly less conspicuous than on prior study. No evidence of
infarction or new intracranial hemorrhage. There is prominence of the
ventricles and sulci suggestive of involutional changes.
A large right parietal subgaleal hematoma appears significantly increased in
size compared to prior study, now measuring up to 1.6 cm. There is no
evidence of fracture. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
1. No evidence of infarction or new intracranial hemorrhage.
2. Redemonstration of prominent subdural hemorrhage along the superior falx
and left tentorial membrane, minimally decreased in size compared to prior
study.
3. Several areas of subarachnoid hemorrhage in the bilateral frontal and
temporal lobes appear slightly less conspicuous than on prior study.
4. Large right parietal subgaleal hematoma appears significantly increased in
size compared to prior study, now measuring up to 1.6 cm.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
INDICATION: ___ hx total gastrectomy RNY esophagoJ ___ for gastric adenoCA
p/w 1 wk abd pain CT c/f afferent loop obs c/b inpt fall SAH/SDH s/p ___
enteroenterostomy, feeding J-tube placement// Recent fall. Trauma? Recent
fall. Trauma?
IMPRESSION:
No comparison. A pelvis over view as well as 2 projections of the left hip
are provided. Moderate degenerative changes at the level of both hip joints.
No evidence of fracture. Multiple phleboliths project over the pelvis. Mild
degenerative changes at the level of the sacroiliac joints.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old woman with afferent loop obstruction s/p ___
enteroenterostomy, feeding J tube placement.// Evaluate for seroma/hematoma.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the midline laparotomy wound.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
midline laparotomy wound.
Deep to the surgical staple line, there is a 5.0 x 1.2 x 2.1 cm heterogeneous,
hypoechoic collection, consistent with a hematoma or complex seroma. No
internal color flow is seen. A drain is demonstrated deep to the fascia.
IMPRESSION:
5.0 x 1.2 x 2.1 cm collection deep to the inferior aspect of the midline
laparotomy site, differential diagnosis includes hematoma or a complex seroma.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with RLE swelling.// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: No relevant comparison identified.
FINDINGS:
There is moderate to severe soft tissue swelling overlying the right posterior
knee. There is normal compressibility, flow, and augmentation of the right
common femoral, femoral, and popliteal veins. Normal color flow demonstrated
in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Moderate to severe soft tissue swelling overlying the right posterior knee.
No evidence of deep venous thrombosis in the right lower extremity veins.
Gender: F
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Other partial intestinal obstruction, Epigastric pain
temperature: 97.4
heartrate: 66.0
resprate: 18.0
o2sat: 99.0
sbp: 169.0
dbp: 72.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ ___ yo F with hx of total gastrectomy with RNY
esophagojejunostomy, D2 lymphadenectomy, and Witzel jejunostomy
(since removed) ___ for T2aN0 gastric adenoCA who presented
on ___ to ___ ED for acute epigastric pain. CT A/P was
obtained which revealed dilated small bowel thought to be
consistent with afferent loop obstruction. Acute care surgery
was consequently consulted in the ED. Patient was admitted under
ACS on ___ for further evaluation and management.
Overnight ___ patient fell unwitnessed while getting out of
bed, striking head. Non-contrast HCT revealed small left sided
subarachnoid and parafalcine subdural hemorrhage. She was
evaluated by neurosurgery who did not recommend operative
management. The patient had a repeat fall with head strike
without associated changes on imaging later in her hospital
course. She fortunately did not sustain any ongoing neurologic
deficits from either fall.
On ___ patient underwent uncomplicated ___
enteroenterostomy and placement of jejunostomy with EBL of 20
mL. She was noted to be stable in the PACU s/p 1 unit pRBC. She
was ___ transferred to the floor. On discharge her tube feeds
were at goal and she tolerating a (small) clear liquid PO diet.
On ___ the renal team was consulted for progressive
hyponatremia that initially developed on ___. They felt this was likely SIADH in the setting of
subarachnoid hemorrhage and recommended fluid restriction and
appropriate workup, with expectation of improvement as
intracranial hemorrhage improves. The endocrine service was also
consulted and after workup were in agreement this was likely
SIADH. They agreed with the renal team's recommendation to
restrict PO intake to <1L and to continue trending her sodiums
at her rehab facility. There is no place for salt tabs or
vaptans at this time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amoxicillin / strawberry / Cephalosporins / vancomycin /
valproic acid / olanzapine
Attending: ___.
Chief Complaint:
elevated LFTs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o male w/ a PMHx of recently diagnosed
seizures, GAS meningitis & bacteremia, s/p multiple ENT surgical
procedures for source control of mastoiditis/cranial abscess and
DRESS ___ anti-epileptics and/or multiple abx received during
prior admission who presents from ___ office after having LFTs
checked that showed uptrending LFTs.
He was first hospitalized ___ for seizures in the
setting of marijuana use and fall then found to have GAS
meningitis & bacteremia then received multiple ENT surgical
procedures for source control of who was again hospitalized
___ where he initially presented with facial swelling &
rash, ultimately diagnosed with DRESS & drug-induced liver
injury
thought to be secondary to previous anti-epileptic or antibiotic
therapy. His LFTs downtrended prior to discharge but when
rechecked at PCP had ___ again.
Patient reports no symptoms, stating that he feels as if his
rash
is over all better. He denies any chest pain, shortness of
breath
or numbness, weakness, tingling, nausea, vomiting. He denies any
burning or itching. He states that he has been compliant with
his
medications. He has not had any further headaches, visual
changes, or seizure/neurologic symptoms.
In the ED, initial VS were: T98.0, HR 122, BP 156/89, RR16, SaO2
100% RA
ECG:
Labs showed:
14.7>12.5/38.0<270
135|100|15
============<138
4.4|24|0.7
ALT: 581 AP: 76 Tbili: 0.4 Alb: 3.9
AST: 128
Imaging showed:
CXR
Left upper extremity PICC terminates in the mid to low SVC.
There
is no focal consolidation. No pleural effusion or pneumothorax.
Cardiomediastinal silhouette is within normal limits
Consults:
Hepatology- admit to medicine for DILI work up
Patient received: No medications in ED
Transfer VS were:T 97.7, HR 87, BP132/75, RR16, SaO2 98% RA
On arrival to the floor, patient recounts the above history
Past Medical History:
- Asthma
- Multiple bilateral ear infections, s/p bilateral tympanostomy
tubes and reported "mastoid procedures"
- seizures
- meningitis
- R temporal lobe abscess
- bilateral mastoiditis
___: Right mastoidectomy, myringotomy w/tube insertion
___: Stereotactic drainage of right temporal abscess
___: Right craniotomy for resection/evacuation of abscess
Social History:
___
Family History:
Diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T98.4 PO, BP118/68, HR 85 SaO297%RA
GENERAL: NAD, sitting up in bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, mild swelling on left zygomatic arch area. No tenderness to
palpation on skull or face, no fluctuance
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, CN2-12
intact
SKIN: Diffusely mildly erythematous on face and UE (improved per
patient), some healing scabs which patient reports he picked on
UE, dry desquamation of ___, no active looking lesions
DISCHARGE PHYSICAL EXAM
VS: 97.8 PO 133 / 86 69 18 100 RA
GENERAL: NAD, lying down in bed
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva,
MMM, mild swelling on left zygomatic arch area. No tenderness to
palpation on skull or face, no fluctuance
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: Diffusely mildly erythematous on face and UE (improved per
patient), some healing scabs which patient reports he picked on
UE, improved desquamation of ___
___ Results:
ADMISSION LABS
___ 02:42PM WBC-13.9* RBC-3.84* HGB-12.3* HCT-38.4*
MCV-100* MCH-32.0 MCHC-32.0 RDW-14.9 RDWSD-53.9*
___ 02:42PM ALT(SGPT)-639* AST(SGOT)-198* ALK PHOS-78 TOT
BILI-0.4
___ 09:44PM WBC-14.7* RBC-3.96* HGB-12.5* HCT-38.0*
MCV-96 MCH-31.6 MCHC-32.9 RDW-14.6 RDWSD-51.2*
___ 09:44PM NEUTS-66.2 ___ MONOS-7.4 EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-9.71* AbsLymp-3.70 AbsMono-1.08*
AbsEos-0.01* AbsBaso-0.03
___ 09:44PM ___ PTT-25.6 ___
___ 09:44PM GLUCOSE-138* UREA N-15 CREAT-0.7 SODIUM-135
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-24 ANION GAP-11
___ 09:44PM ALT(SGPT)-581* AST(SGOT)-128* ALK PHOS-76 TOT
BILI-0.4
___ 09:44PM ALBUMIN-3.9
___ 09:44PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 09:49PM LACTATE-1.6
PERTINENT/DISCHARGE LABS
___ 06:23AM BLOOD WBC-14.1* RBC-3.79* Hgb-12.2* Hct-37.0*
MCV-98 MCH-32.2* MCHC-33.0 RDW-14.7 RDWSD-53.1* Plt ___
___ 06:23AM BLOOD ALT-511* AST-105* LD(LDH)-229 AlkPhos-72
TotBili-0.4
___ 05:41AM BLOOD WBC-14.0* RBC-4.01* Hgb-12.7* Hct-39.4*
MCV-98 MCH-31.7 MCHC-32.2 RDW-14.9 RDWSD-53.8* Plt ___
___ 05:41AM BLOOD Glucose-83 UreaN-17 Creat-0.5 Na-139
K-4.0 Cl-104 HCO3-26 AnGap-9*
___ 05:41AM BLOOD ALT-428* AST-71* CK(CPK)-16* AlkPhos-97
TotBili-0.3
___ 05:41AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.0
IMAGING/STUDIES
MRI brain w/ and w/o contrast ___- Interval decrease in size
of the known right temporal abscess with associated decrease in
surrounding vasogenic edema. The right dural/pachymeningeal
enhancement appear similar to slightly improved compared to
prior.
Opacification of the right mastoid air cells and middle ear
cavity appear similar compared to prior, but no restricted
diffusion to suggest abscess formation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with PICC// PICC placement?
COMPARISON: Chest radiograph ___
FINDINGS:
Portable AP view of the chest provided.
Left upper extremity PICC terminates in the mid to low SVC. There is no focal
consolidation. No pleural effusion or pneumothorax. Cardiomediastinal
silhouette is within normal limits.
IMPRESSION:
Left upper extremity PICC terminates in the mid to low SVC.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with h/o GAS meningitis and abscess please
evaluate for interval change// evaluate prior abscess
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: Prior MR done ___
FINDINGS:
The right temporald rim enhancing collection is decreased in size currently
measuring 22 x 18 mm in diameter (26 x 27 mm previously) with the
superolateral extending surgical drainage tract also being decreased in size
currently measuring 7 mm in diameter (previously 10 mm). Previously noted
restricted diffusion as well as surrounding edema in the right temporal lobe
is improved compared to prior. The right dural/pachymeningeal enhancement
appear similar to slightly improved compared to prior.
There is mild dilatation of the temporal horn of the right lateral ventricle
which may be ex vacuo in nature.
There is persistent opacification of the right middle ear cavity and mastoid
air cells with mild enhancement, but no restricted diffusion (suggesting
granulation tissue).
The pituitary appears normal. The craniocervical junction appears normal.
The orbits appear normal. The paranasal sinuses are clear. The intracranial
arteries demonstrate normal T2 flow void.
IMPRESSION:
Interval decrease in size of the known right temporal abscess with associated
decrease in surrounding vasogenic edema.
The right dural/pachymeningeal enhancement appear similar to slightly improved
compared to prior.
Opacification of the right mastoid air cells and middle ear cavity appear
similar compared to prior, but no restricted diffusion to suggest abscess
formation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs, Rash
Diagnosed with Gen skin eruption due to drugs and meds taken internally, Adverse effect of cephalospor/oth beta-lactm antibiot, init, Oth places as the place of occurrence of the external cause, Acute viral hepatitis, unspecified, Epilepsy, unsp, not intractable, without status epilepticus
temperature: 98.0
heartrate: 122.0
resprate: 16.0
o2sat: 100.0
sbp: 156.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | SUMMARY STATEMENT
Mr. ___ is a ___ with PMHx of childhood asthma and
multiple B/L ear infections s/p tympanostomy tubes, right upper
molar infection s/p extraction, and a recent hospitalization
(___) for GAS meningitis/bacteremia (right mastoiditis s/p
multiple surgical interventions for source control) c/b seizures
and then DRESS/DILI, who presents with worsening of previously
down-trending LFTs.
ACUTE ISSUES
#Acute liver injury: Concern for reactivation of DRESS syndrome
vs. drug-induced liver injury, which can relapse even weeks
after in the setting of discontinuation of culprit drug. Unsure
which drug was original offending agent, however prior
vancomycin, meropenem, and Keppra are all possibilities. Given
elevated LFTs, Keppra and meropenem were initially held. The
patient's LFTs rapidly began to downtrend. Neurology was
consulted and recommended switching patient to lacosamide for
seizure prophylaxis. ID was consulted and recommended switching
patient to daptomycin for brain abscess. The patient was
continued on prednisone, as well as his home calcium and
famotidine.
#H/O GAS meningitis and temporal abscess: Patient was scheduled
for head MRI and ID follow up in the coming week. No recurrence
of any symptoms and no fevers. Patient had been taking IV
meropenem at home as instructed. Last dose 4PM on ___. The
patient was switched to daptomycin without side effects. Repeat
MRI brain showed interval decrease in size of the abscess.
#Seizures: Initially held Keppra, before switching to lacosamide
for seizure prophylaxis.
#Leukocytosis: Approximately stable since last admission. Likely
from steroids vs. DRESS. No infectious signs or symptoms.
TRANSITIONAL ISSUES
[]New medications: IV Daptomycin 650mg q24h (at least until ID
follow up on ___ lacosamide 100 bid (at least until neuro
follow up ___
[]ID working on re-scheduling outpatient appointment and repeat
brain MRI
[]Patient continued on previously documented prednisone taper
(see discharge medications)
[]Consider re-sending LFTs at upcoming dermatology appointment
[]OPAT labs: weekly CK, CBC, BUN/Cr
#CODE: FULL CODE (presumed)
#CONTACT: Father ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
low grade fevers i/s/o robotic pyelolithotomy and previous urine
leak
Major Surgical or Invasive Procedure:
___: right ureteral stent exchange
History of Present Illness:
Ms. ___ is a ___ y/o female well known to our service who
underwent right robotic partial nephrectomy and pyelolithotomy
(for a large staghorn calculus) on ___. The renal pelvic
tissue was thin and friable due to inflammation from the stone
and the closure was poor; she developed a urine leak and was
discharged home with Foley catheter, ureteral stent, and
surgical drain in place. She was subsequently readmitted ___ -
___ with an infected urinoma for which she had a drain
placed by ___. Blood and urine cultures on admission were
negative but culture of the purulent material from the urinoma
grew multiple organisms; initially only Pseudomonas aeruginosa
was speciated and she was sent home on a 14-day course of PO
ciprofloxacin. Full speciation/sensitivities were requested on
the culture and Enterococcus and E. coli were additionally
isolated.
In the interval she has done well. Her surgical ___ drain and
Foley catheter have been removed, leaving only the ___ drain
still in place. Her prednisone dose was tapered to 2.5 mg, then
to 1 mg and was discontinued entirely ___ days ago. Her
methotrexate was increased from 7.5 to 10 mg. She completed the
PO ciprofloxacin
two days ago.
This morning she felt very well, but around 1330 today she began
to feel hot. Her temperature was approximately 100 degrees at
that time and subsequently increased to 101.3. She had some
somewhat increased fatigue but no chills, sweats, or other
localizing symptoms. She has been having BMs and passing flatus.
There has been no dysuria, frequency, urgency, or change in the
appearance of the urine. She called in and was advised to
present to the ED for evaluation.
In triage her HR was elevated to 133; it subsequently decreased
to the 100s without intervention. Her temperature was initially
100.8 and uptrended to 101.3 while she was being evaluated.
Past Medical History:
- depression
- sarcoidosis
Social History:
___
Family History:
noncontributory
Physical Exam:
Exam on admission:
- AAOx4, WDWN female resting comfortably in bed, NAD
- skin WWP, non-diaphoretic
- breathing unlabored on RA
- abd soft, ND with minimal tenderness to even deep palpation of
RUQ/RLQ; well-healed robotic port sites, no erythema,
induration,
discharge, fluctuance; ___ drain in place to right flank draining
clear straw-colored fluid
- no CVAT
- no ___ edema or tenderness
Exam on discharge:
- AAOx4, WDWN female resting comfortably in bed, NAD
- skin WWP, non-diaphoretic
- breathing unlabored on RA
- abd soft, ND, NT; no CVAT
- ___ drain site intact with c/d/i dressing in place
- no ___ edema or tenderness
Pertinent Results:
___ 08:30PM BLOOD WBC-9.8 RBC-3.93# Hgb-11.1* Hct-34.8
MCV-89 MCH-28.2 MCHC-31.9* RDW-13.2 RDWSD-43.2 Plt ___
___ 09:15AM BLOOD WBC-7.5 RBC-3.30* Hgb-9.4* Hct-29.3*
MCV-89 MCH-28.5 MCHC-32.1 RDW-13.3 RDWSD-43.7 Plt ___
___ 07:40AM BLOOD WBC-5.1 RBC-3.38* Hgb-9.5* Hct-30.1*
MCV-89 MCH-28.1 MCHC-31.6* RDW-13.5 RDWSD-44.0 Plt ___
___ 08:30PM BLOOD Glucose-126* UreaN-13 Creat-1.4* Na-134
K-4.0 Cl-97 HCO3-23 AnGap-18
___ 09:15AM BLOOD Glucose-160* UreaN-11 Creat-1.2* Na-138
K-3.7 Cl-102 HCO3-23 AnGap-17
___ 07:40AM BLOOD Glucose-111* UreaN-8 Creat-1.2* Na-143
K-4.3 Cl-105 HCO3-25 AnGap-17
___ 09:21AM BLOOD Glucose-164* UreaN-13 Creat-1.3* Na-141
K-3.8 Cl-102 HCO3-26 AnGap-17
___ 08:40PM BLOOD Lactate-2.0
___ 09:15PM URINE Color-Straw Appear-Clear Sp ___
___ 09:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 09:15PM URINE RBC-3* WBC-18* Bacteri-FEW Yeast-NONE
Epi-2
___ 9:15 pm URINE
URINE CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
___ 11:31 am URINE Site: CYSTOSCOPY RIGHT RENAL
PELVIC .
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. ~400 CFU/mL.
CTU ___:
Final Report
EXAMINATION: CTU with contrast, including delayed imaging
INDICATION: ___ w/ complicated urologic history, h/o urinoma
now with fever. please obtain ct urogram w/wo contrast with
DELAYED CUTS to eval for collecting system extravasation.
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were
acquired prior to and after intravenous contrast administration
with the patient in prone position. The non-contrast scan was
done with low radiation dose technique. The contrast scan was
performed with split bolus technique.
Oral contrast was not administered. Coronal and sagittal
reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy
(Body) DLP = 651.5 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy
(Body) DLP = 9.6 mGy-cm.
3) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy
(Body) DLP = 652.2 mGy-cm.
Total DLP (Body) = 1,313 mGy-cm.; Acquisition sequence: 1)
Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 11.4 mGy (Body) DLP
= 614.3 mGy-cm.
Total DLP (Body) = 614 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without evidence of focal lesions.
ADRENALS: The left adrenal gland is unremarkable. The right
adrenal gland is not well visualized.
URINARY: There is a right double-J ureteral stent is unchanged,
but the proximal pigtail is inferior to the obstructed renal
pelvis, as before. There is a right posterior approach pigtail
catheter at the site of a prior right perinephric fluid
collection. The fluid collection has largely resolved. There
is trace fluid and fibrofatty proliferation surrounding in this
region. There is a 0.5 cm stone in the right renal pelvis
(___). Again seen a prominent right renal collecting system,
consistent with hydronephrosis. There are post-treatment
changes from prior partial nephrectomy. There is a 1.2 cm
hypodense lesion in the left kidney, with Hounsfield units
slightly above expected for a simple cyst, possibly representing
a hemorrhagic cyst. There is a 0.4 cm nonobstructive nephrolith
in the left kidney. The distal ureters and bladder are
unremarkable.
On delayed imaging, there is a right persistent striated
nephrogram without evidence of extravasated contrast. A
persistent striated nephrogram, likely secondary to obstruction.
A portion of the cortex is nonenhancing (___) at the site of
the prior partial nephrectomy.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding.
Punctate nonobstructive appendiceal stone (___). The appendix
is otherwise normal.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: There are few prominent, though nonenlarged right
aortocaval lymph nodes, measuring up to 1.0 x 0.6 cm (___).
There is no retroperitoneal or mesenteric lymphadenopathy.
There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No evidence of collecting system extravasation. No urinoma.
2. The previously seen right perinephric fluid collection has
largely resolved with minimal persistent trace fluid.
3. There is a right double-J ureteral stent and a right
posterior approach pigtail catheter at the site of the previous
right perinephric fluid collection. The superior pigtail of the
double-J ureteral stent is inferior to the obstructed renal
pelvis, as before.
4. On delayed imaging, there is a right persistent striated
nephrogram without evidence of extravasated contrast. A
persistent striated nephrogram, likely secondary to obstruction.
A portion of the cortex is nonenhancing at the site of the prior
partial nephrectomy.
KUB ___:
INDICATION: ___ year old woman s/p right ureteral stent exchange
// assess stent position
TECHNIQUE: Supine abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
Compared to ___, the right double-J ureteral stent
has been moved is such that the proximal and is present in the
expected location of the right renal pelvis and the distal and
is coiled in the right side of the bladder. A right-sided
percutaneous nephrostomy tube is in unchanged position.
Contrast fills the bladder.
There are no abnormally dilated loops of large or small bowel.
There is a nonspecific, nonobstructive bowel gas pattern.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative changes of the
lumbar spine. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies.
IMPRESSION:
The proximal end of the right double-J ureteral stent is now
curled in the expected location of the right renal pelvis and
the distal end is curled in the right side of the bladder. A
right-sided percutaneous nephrostomy tube is in unchanged
position.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methotrexate Sodium P.F. 10 mg IT QWED
2. FLUoxetine 20 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate Duration: 7 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
6. FLUoxetine 20 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Methotrexate Sodium P.F. 10 mg IT QWED
Discharge Disposition:
Home
Discharge Diagnosis:
fever and partial right renal obstruction following robotic
pyeloplasty
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTU with contrast, including delayed imaging
INDICATION: ___ w/ complicated urologic history, h/o urinoma now with fever.
please obtain ct urogram w/wo contrast with DELAYED CUTS to eval for
collecting system extravasation. // ___ w/ complicated urologic history, h/o
urinoma now with fever. please obtain ct urogram w/wo contrast with DELAYED
CUTS to eval for collecting system extravasation. ; NO_PO contrast; History:
___ with recent CTU now need please obtain delayed phase CT scan in ___
mins in order to assess for accumulation of IV contrast outside kidney.NO_PO
contrast // STAT NON-CON per urology: please obtain delayed phase CT scan in
___ mins in order to assess for accumulation of IV contrast outside kidney.
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy (Body) DLP = 651.5
mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
3) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.9 mGy (Body) DLP = 652.2
mGy-cm.
Total DLP (Body) = 1,313 mGy-cm.; Acquisition sequence:
1) Spiral Acquisition 5.0 s, 54.0 cm; CTDIvol = 11.4 mGy (Body) DLP = 614.3
mGy-cm.
Total DLP (Body) = 614 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The left adrenal gland is unremarkable. The right adrenal gland is
not well visualized.
URINARY: There is a right double-J ureteral stent is unchanged, but the
proximal pigtail is inferior to the obstructed renal pelvis, as before. There
is a right posterior approach pigtail catheter at the site of a prior right
perinephric fluid collection. The fluid collection has largely resolved.
There is trace fluid and fibrofatty proliferation surrounding in this region.
There is a 0.5 cm stone in the right renal pelvis (___). Again seen a
prominent right renal collecting system, consistent with hydronephrosis.
There are post-treatment changes from prior partial nephrectomy. There is a
1.2 cm hypodense lesion in the left kidney, with Hounsfield units slightly
above expected for a simple cyst, possibly representing a hemorrhagic cyst.
There is a 0.4 cm nonobstructive nephrolith in the left kidney. The distal
ureters and bladder are unremarkable.
On delayed imaging, there is a right persistent striated nephrogram without
evidence of extravasated contrast. A persistent striated nephrogram, likely
secondary to obstruction. A portion of the cortex is nonenhancing (___) at
the site of the prior partial nephrectomy.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. Punctate nonobstructive appendiceal stone (___). The appendix is
otherwise normal.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There are few prominent, though nonenlarged right aortocaval
lymph nodes, measuring up to 1.0 x 0.6 cm (___). There is no retroperitoneal
or mesenteric lymphadenopathy. There is no pelvic or inguinal
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of collecting system extravasation. No urinoma.
2. The previously seen right perinephric fluid collection has largely resolved
with minimal persistent trace fluid.
3. There is a right double-J ureteral stent and a right posterior approach
pigtail catheter at the site of the previous right perinephric fluid
collection. The superior pigtail of the double-J ureteral stent is inferior
to the obstructed renal pelvis, as before.
4. On delayed imaging, there is a right persistent striated nephrogram without
evidence of extravasated contrast. A persistent striated nephrogram, likely
secondary to obstruction. A portion of the cortex is nonenhancing at the site
of the prior partial nephrectomy.
Radiology Report
INDICATION: ___ year old woman s/p right ureteral stent exchange // assess
stent position
TECHNIQUE: Supine abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
Compared to ___, the right double-J ureteral stent has been moved
is such that the proximal and is present in the expected location of the right
renal pelvis and the distal and is coiled in the right side of the bladder. A
right-sided percutaneous nephrostomy tube is in unchanged position. Contrast
fills the bladder.
There are no abnormally dilated loops of large or small bowel. There is a
nonspecific, nonobstructive bowel gas pattern.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative changes of the lumbar spine.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
The proximal end of the right double-J ureteral stent is now curled in the
expected location of the right renal pelvis and the distal end is curled in
the right side of the bladder. A right-sided percutaneous nephrostomy tube is
in unchanged position.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Urinary tract infection, site not specified, Fever, unspecified
temperature: 100.8
heartrate: 133.0
resprate: 16.0
o2sat: 98.0
sbp: 130.0
dbp: 72.0
level of pain: 2
level of acuity: 1.0 | Ms. ___ was admitted from the ED on ___ with low grade
fevers to 101.3. She was started on broad coverage with
vancomycin and Zosyn. Repeat CT scan was obtained with delayed
cuts showing no extravasation of contrast from the collecting
system, but a moderate sized stone causing upper pole
hydronephrosis of the right kidney. As before, the right
ureteral stent was quite low and was not draining the upper
pole.
The decision was made to exchange and reposition the ureteral
stent and she was added on for cystoscopy and ureteral stent
exchange, which was performed on ___. A glidewire was
advanced past the stone into the upper pole and a new ___ Fr x 28
cm stent placed over a wire. Retrograde pyelogram showed the
collecting system was intact with trace to no extravasation of
contrast.
The patient did well postoperatively and remained afebrile
throughout her hospital stay aside from the initial night of
admission. Her ___ drain was removed on HD 3 (POD 1) and she was
discharged home later the same day in good condition. She was
given a 10 day course of PO ciprofloxacin and
amoxicillin/clavulante and instructed to make an appointment
with ___ in ___ weeks, and to call the office in two
days to follow up her culture results. She will return for an
interval discussion with Dr. ___ further management
of the stent and stone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal distention, cough
Major Surgical or Invasive Procedure:
___: Transjugular hepatic core biopsy
History of Present Illness:
___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis
referred to ER for workup of increasing bilirubin and abdominal
distension.
She has noticed this increasing abdominal distension over the
last month to weeks with associated weight gain. She denies any
abdominal pain other than mild twinges across the right flank.
She also endorses decreased exercise tolerance over the last
year which she attributes to starting on nadolol but no SOB at
rest or chest pain. She denies any fevers, chills, vomiting,
melena. She is keeping to her low salt diet and is compliant
with her home diuretic regimen.
Patient denies tylenol use but took Dayquil for sore throat
earlier today. She reports flu like symptoms 4 days prior to
presentation.
In the ED, initial vitals were:
- Labs notable for: AST/ALT 242/82, ALP 216, Tbili 5.7. Dbili
2.7, Lip 88, Na 127, Cr 0.9, CO2 18, lactate 1.6, U/A with mod
___, few bact, 7 WBC, 2 Epi, serum/urine tox negative, APAP 8
- Imaging: bedside us-minimal ascites not amenable to drainage
- No medications given.
- Repeat Chem7 notable for Na 132, CO2 21
Hepatology was consulted who recommended bedside ultrasound and
albumin 25% 1g/kg if dry.
Upon arrival to the floor, patient reports right sided abdominal
pain and a chest cold. Abd pain for 2 weeks, ___, distractable,
non-radiating.
Patient is having 3 BM per day.
Denies fevers, chills, dysphagia, sore throat, chest pain,
peripheral edema, orthopnea, SOB, DOE with normal activities,
other abd pain, N/V/D, black or bloody stools, dysuria,
hematuria, focal weakness, numbness or falls.
Past Medical History:
- Primary biliary cirrhosis
* Liver biopsy (___): features of PBC with gramulomas around
the bile dicts and positive AMA
* ___ positive at 1:640 but no features of autoimmune hepatitis
* EGD (___) with grade I varices, mild gastropathy
Social History:
___
Family History:
- Mother had PBC
- No other history of familial disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
VITAL SIGNS - 98.4 121/70 70 16 98% RA
GENERAL - WNWD female in NAD, laying in bed
HEENT - trace icterus, PERRL, EOMI, MOM, OP clear
NECK - supple, no LAD, no elevated JVD
CARDIAC - RRR, normal S1S2, no M/R/G
LUNGS - NLB on RA, CTAB
ABDOMEN - soft, distended, tympanitic, non-tender except for an
isolated point on lower right axillary line, no
rebound/guarding, NABS
EXTREMITIES - WWP, no cyanosis or edema
NEUROLOGIC - A&O, CN II-XII intact grossly, SILT, MAE, no
asterixis
SKIN - warm, dry, jaundiced
DISCHARGE PHYSICAL EXAM
==================
VITAL SIGNS - 98.2 103/67-121/63 58-62 18 96%RA
GENERAL - ___ female in NAD, laying in bed
HEENT - trace icterus, PERRL, EOMI, MOM, OP clear
NECK - supple, no LAD, no elevated JVD
CARDIAC - RRR, normal S1S2, no M/R/G
LUNGS - NLB on RA, lungs clear to auscultation bilaterally
ABDOMEN - soft, mildly distended, non-tender except for an
isolated point on lower right axillary line, no
rebound/guarding, NABS. Para site dressed, clean dry and intact
EXTREMITIES - WWP, no cyanosis. trace pedal edema bilaterally.
NEUROLOGIC - A&O, CN II-XII intact, no asterixis
SKIN - warm, dry, jaundiced
Pertinent Results:
ADMISSION LABS
==========
___ 05:37PM BLOOD WBC-3.2* RBC-3.19* Hgb-11.6 Hct-33.2*
MCV-104* MCH-36.4* MCHC-34.9 RDW-17.2* RDWSD-65.3* Plt ___
___ 05:37PM BLOOD Neuts-68.9 Lymphs-14.3* Monos-12.5
Eos-3.7 Baso-0.3 Im ___ AbsNeut-2.21 AbsLymp-0.46*
AbsMono-0.40 AbsEos-0.12 AbsBaso-0.01
___ 05:37PM BLOOD ___ PTT-34.5 ___
___ 05:37PM BLOOD Glucose-107* UreaN-21* Creat-0.9 Na-127*
K-7.0* Cl-97 HCO3-18* AnGap-19
___ 11:55AM BLOOD ALT-94* AST-169* AlkPhos-243*
TotBili-7.7* DirBili-4.8* IndBili-2.9
___ 05:37PM BLOOD Albumin-2.5* Calcium-8.6 Phos-3.1 Mg-2.1
___ 05:24AM BLOOD calTIBC-161* Ferritn-166* TRF-124*
___ 05:37PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
NOTABLE LABS
=========
___ 05:31AM BLOOD ALT-65* AST-122* AlkPhos-216*
TotBili-4.9*
___ 05:55AM BLOOD ALT-50* AST-97* AlkPhos-180* TotBili-4.0*
___ 05:37PM BLOOD Lipase-88*
___ 05:24AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.6 Iron-67
Cholest-122
___ 05:24AM BLOOD calTIBC-161* Ferritn-166* TRF-124*
___ 05:55AM BLOOD %HbA1c-4.2 eAG-74
___ 05:24AM BLOOD Triglyc-65 HDL-19 CHOL/HD-6.4 LDLcalc-90
___ 09:45PM BLOOD Osmolal-283
___ 05:24AM BLOOD 25VitD-9*
___ 05:17AM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 05:17AM BLOOD AMA-NEGATIVE
___ 05:24AM BLOOD CEA-8.1*
___ 05:17AM BLOOD ___ * Titer-1:160
___ 11:55AM BLOOD AFP-2.9
___ 05:17AM BLOOD IgG-1060 IgM-117
___ 11:55AM BLOOD IgA-1416*
___ 05:31AM BLOOD HIV Ab-Negative
___ 11:55AM BLOOD tTG-IgA-15
___ 05:17AM BLOOD HCV Ab-Negative
___ 05:15PM BLOOD CMV VL-NOT DETECT
CA ___ 12
MICROBIOLOGY
=========
QUANTIFERON(R)-TB GOLD INDETERMINATE
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
ASCITES FLUID
=========
___ 10:45AM ASCITES WBC-118* RBC-458* Polys-0 Lymphs-23*
___ Mesothe-12* Macroph-65*
___ 10:45AM ASCITES TotPro-0.8 Glucose-116 Creat-0.7
LD(LDH)-57 TotBili-0.8 Albumin-0.4
PATHOLOGY
========
Liver, transjugular needle core biopsy:
Markedly fragmented hepatic parenchyma demonstrating:
1. Features consistent with cirrhosis (confirmed by trichrome
stain).
2. Focally moderate portal/septal mononuclear inflammation,
including prominent plasma cells, with
focal periportal extension and mild associated collapse
(confirmed by reticulin stain).
3. Focally prominent balloon degeneration with abundant
intracytoplasmic hyalin, minimal
predominantly small droplet steatosis, and associated
neutrophils.
4. Frequent lobular neutrophils, including scattered
neutrophilic aggregates; immunohistochemical
stain for CMV is negative, with satisfactory control.
5. Mild intrahepatocytic and focal canalicular cholestasis.
6. Lymphocytic cholangitis with bile duct damage and foci of
ductular proliferation with scattered
associated neutrophils
7. No absolute bile ductopenia identified (immunohistochemical
stain for CK7 is evaluated).
Note: The features appear to be those of two concomitant
processes: involvement by patient's
known PBC with autoimmune hepatitis overlap syndrome (as
evidenced by the lymphoplasmacytic
inflammation with focal ___ extension and mild
associated collapse), and a superimposed
toxic/metabolic injury (demonstrated by abundant hyalin and
focally prominent lobular neutrophils
with focal balloon degeneration).
Compared to the patient's prior biopsy (___), the
mononuclear inflammatory features
compatible with patient's known PBC/AIH overlap syndrome share
very focal morphologic similarity
to the current sample, with now evident cirrhosis and the above
described toxic/metabolic injury. Dr.
___ was notified of the preliminary results via telephone
on ___. The case was reviewed
with Dr. ___, who concurs.
IMAGING/STUDIES
===========
___ ABDOMINAL ULTRASOUND
1. Mild ascites.
2. Very nodular heterogeneous coarse hepatic architecture
consistent with the patient's known cirrhosis. Although the
degree of heterogeneity makes it difficult for ultrasound to
assess for lesions no gross liver mass is visualized.
3. Patent hepatic vasculature. A patent umbilical vein is
noted.
4. Splenomegaly.
___ CXR PA/LAT
1. Increased prominence of the bilateral hila since ___ can be
concerning
for sarcoidosis.
2. Low lung volumes with left basilar opacities, which may be
due to
atelectasis. However, concurrent pneumonia is difficult to
exclude in the
appropriate clinical setting.
___ CT CHEST
1. Diffuse bronchial wall thickening may reflect bronchitis.
2. Multiple small nodular opacities measuring 4 mm or less may
reflect mild
atypical pneumonia or inflammatory changes. Consider follow-up
chest CT after
resolution of acute illness.
3. Mild bilateral lower lobe atelectasis.
4. Liver cirrhosis with ascites and splenomegaly.
___ MRI LIVER
Images are compromised by patient motion.
Hepatic cirrhosis. Large volume ascites. Varices. Mild
splenomegaly.
There is no liver mass. Consider mild cholangitis.
Patent portal vein.
Multiple pancreatic side-branch IPMNs, some have enlarged,
largest 1.1 cm.
___ TTE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Normal left ventricular wall
thickness, cavity size, and regional/global systolic function
(biplane LVEF = 70 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is high normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. No valvular
pathology or pathologic flow identified. High normal estimated
PA systolic pressure. Mild biatrial enlargement.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
DISCHARGE LABS
==========
___ 06:33 WBC7.4 Hb10.7* Hct31.9* Plt111*
___ 06:33 PT17.0* PTT 34.3 INR 1.6*
___ 06:33 Glucose 78 BUN 24* Cr 0.7 Na 140K4.1Cl 103
HCO3 25 AG16
___ 06:33 ALT 57* AST 87* ALK PHOS173* TBILI 5.4*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 20 mg PO DAILY
2. Ursodiol 1000 mg PO QAM
3. Furosemide 20 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Alendronate Sodium 70 mg PO QSAT
6. AzaTHIOprine 75 mg PO DAILY
7. Budesonide 6 mg PO DAILY
8. Ocaliva (obeticholic acid) 5 mg oral DAILY
9. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
10. Ursodiol 500 mg PO QPM
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth Every 12 hours Disp #*60 Tablet Refills:*1
2. Levofloxacin 750 mg PO DAILY
Last dose is on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*6
Tablet Refills:*0
3. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*60 Tablet
Refills:*3
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*2
5. Vitamin D ___ UNIT PO 1X/WEEK (TH)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth Once Weekly on ___ Disp #*11 Capsule Refills:*0
6. AzaTHIOprine 125 mg PO DAILY
RX *azathioprine 50 mg 2.5 tablet(s) by mouth Daily Disp #*90
Tablet Refills:*2
7. Ursodiol 500 mg PO BID
RX *ursodiol 500 mg 1 tablet(s) by mouth Every 12 hours Disp
#*60 Tablet Refills:*3
8. Furosemide 20 mg PO DAILY
9. Nadolol 20 mg PO DAILY
10. Spironolactone 50 mg PO DAILY
11. HELD- Budesonide 6 mg PO DAILY This medication was held. Do
not restart Budesonide until you discuss this with your liver
doctor
12. HELD- Ocaliva (obeticholic acid) 5 mg oral DAILY This
medication was held. Do not restart Ocaliva until you discuss
this with your liver doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Primary biliary cirrhosis with autoimmune hepatitis
Community acquired pneumonia, suspected bacterial source
Secondary:
Ascites
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with decompensated PBC with worsening abd
distension // paracentesis
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Abdominal ultrasound dated ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 3 L of clear, straw-colored fluid were removed. Fluid
samples were submitted to the laboratory for cell count, differential, and
culture.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3 L of fluid were removed.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with PBC presenting with elevated LFT and cough
// evidence of infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___
FINDINGS:
The lungs are hypoinflated with bronchovascular crowding and left basilar
opacities, possibly representing atelectasis but concurrent infection is
difficult to exclude in the appropriate clinical setting. Increased
prominence of the bilateral hila can be concerning for sarcoidosis. There is
no pulmonary edema or pneumothorax. The cardiomediastinal silhouette is
unchanged.
IMPRESSION:
1. Increased prominence of the bilateral hila since ___ can be concerning
for sarcoidosis.
2. Low lung volumes with left basilar opacities, which may be due to
atelectasis. However, concurrent pneumonia is difficult to exclude in the
appropriate clinical setting.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 2:20 ___, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis
referred to ER for workup of increasing bilirubin and abdominal distension.
// evaluation for liver mass, portal venous thrombosis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
COMPARISON: CT ___, MRI ___
FINDINGS:
Patient motion compromises images.
Lower Thorax: There is trace right pleural effusion. Right basilar opacities,
likely represent atelectasis. There is minimal left basilar atelectasis.
Liver: There is large volume ascites, significantly increased since prior
exam. Nodular, shrunken appearance of the liver, consistent with hepatic
cirrhosis. There upper abdominal varices, including paraesophageal varices.
There are no hepatic masses. Small focus of subtle enhancement in the segment
7 right hepatic lobe series 1001, image 68, has branching pattern, consider
cholangitis.
Biliary: There is mild gallbladder wall edema, without enhancement, likely
reactive. There is no bile duct dilatation.
Pancreas: There few small nonenhancing pancreatic cystic lesions, consistent
with side branch IPMNs, some have enlarged, largest measures 1.1 cm, compared
with 0.8 cm on prior.
Spleen: Spleen is enlarged measuring 14 cm, mildly more prominent since prior.
Adrenal Glands: Normal
Kidneys: Normal
Gastrointestinal Tract: No abnormalities
Lymph Nodes: No adenopathy
Vasculature: Patent portal vein. Varices. Patent major visualized arteries.
Osseous and Soft Tissue Structures: No abnormalities.
IMPRESSION:
Images are compromised by patient motion.
Hepatic cirrhosis. Large volume ascites. Varices. Mild splenomegaly.
There is no liver mass. Consider mild cholangitis.
Patent portal vein.
Multiple pancreatic side-branch IPMNs, some have enlarged, largest 1.1 cm.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis
referred to ER for workup of increasing bilirubin and abdominal distension
with cough and possible pneumonia on CXR // evaluate for evidence of
inflammation or pneumonia
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 36.5 cm; CTDIvol = 11.6 mGy (Body) DLP = 422.1
mGy-cm.
Total DLP (Body) = 422 mGy-cm.
COMPARISON: None prior
FINDINGS:
Thyroid is unremarkable. Supraclavicular, axillary, and mediastinal lymph
nodes are not pathologically enlarged. Thoracic aorta and main pulmonary
artery are normal caliber. There is no pleural effusion or pericardial
effusion.
Diffuse bronchial wall thickening is noted. Small peribronchovascular dense
airspace opacities are likely atelectasis. Mild ground-glass opacities in
both lungs posteriorly are likely mild pulmonary edema. Multiple nodular
opacities in a peripheral distribution are noted.
Largest nodule measures 4 mm in right upper lobe (4:86). Other nodules are
smaller (4:62, 102, 109, 122)
Limited evaluation of the upper abdomen is notable for liver cirrhosis.
Enlarged spleen measures 13.8 cm. Ascites is small to moderate size.
Trace amount of pneumoperitoneum is likely related to recent paracentesis.
IMPRESSION:
1. Diffuse bronchial wall thickening may reflect bronchitis.
2. Multiple small nodular opacities measuring 4 mm or less may reflect mild
atypical pneumonia or inflammatory changes. Consider follow-up chest CT after
resolution of acute illness.
3. Mild bilateral lower lobe atelectasis.
4. Liver cirrhosis with ascites and splenomegaly.
Radiology Report
INDICATION: ___ with PMHx Primary biliary cirrhosis and autoimmune hepatitis
referred to ER for workup of increasing bilirubin. // Concern for autoimmune
hepatitis vs. PBC vs. fibrotic changes
COMPARISON: CT of the chest dated ___.
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: 0.25 mcg of fentanyl IV. 1% lidocaine was injected in the skin
and subcutaneous tissues overlying the access site.
MEDICATIONS: None.
CONTRAST: 5 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 6.9 min, 41 mGy
PROCEDURE: 1. Right internal jugular venous access using ultrasound.
2. Right atrial and hepatic venous and balloon-occluded portal pressure
measurements.
3. Transjugular hepatic core biopsy with 4 passes.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The neck was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Hard copy
ultrasound images were obtained before and after intravenous access.
Subsequently a Nitinol wire was passed into the right atrium using
fluoroscopic guidance. A small incision was made at the needle entry site. The
needle was exchanged for a micropuncture sheath. The Nitinol wire was removed
and a Amplatz wire was advanced distally into the IVC.
A 9 ___ sheath was advanced over the wire into the inferior vena cava.
Using a C2 Cobra catheter and a glide wire, access was obtained in the right
hepatic vein. Appropriate position was confirmed with contrast injection and
fluoroscopy. The glide wire was exchanged for ___ wire and the sheath was
advanced into the proximal right hepatic vein. Then, a 0.5 mm occlusion
balloon was advanced over the wire into the distal right hepatic vein. The
wire was then removed and right atrial and hepatic venous and balloon-occluded
portal pressure measurements were obtained after balloon occlusion.
The balloon was then removed and a liver access sheath was advanced into the
liver in appropriate position. The biopsy needle was advanced through the
liver access sheath and four 18 gauge core biopsies were acquired while
pointing the biopsy sheath anteriorly. The core biopsies were placed in
formalin and labeled for pathology.
The wire, catheters and core biopsy needle were then removed, pressure held
until hemostasis was achieved and sterile dressings were applied. The patient
tolerated the procedure well and there were no immediate post-procedure
complications.
FINDINGS:
1. Right atrial pressure of 13 and balloon-occluded portal pressure
measurement of 29.
2. Four 18G core biopsies of the liver acquired through transjugular access.
IMPRESSION:
1. Successful transjugular liver biopsy.
2. Portosystemic gradient of 16 mmHg
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaundice, Abdominal distention
Diagnosed with Cholangitis
temperature: 98.2
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 78.0
level of pain: 5
level of acuity: 2.0 | ___ year old woman with PMHx Primary biliary cirrhosis and
autoimmune hepatitis referred to ER for workup of increasing
bilirubin and abdominal distension concerning for progression of
autoimmune hepatitis vs. PBC/cirrhosis progression. Ascites was
found on ultrasound and large volume paracentesis was performed
with no evidence of SBP. Transjugular liver biopsy was performed
showing inflammation consistent with autoimmune hepatitis and
toxic metabolic injury. Her course was complicated by pneumonia
with fever for which she was treated for community acquired
pneumonia.
# Primary Billiary Cirrhosis: Child B, MELD 21 on admission.
History of varices s/p banding. Decompensated by jaundice,
ascites and varices with INR, bilirubin above baseline with
unclear etiology. Per history, the patient had been taking
azathioprine 75mg daily but only 15 days per month. A
transjugular liver biopsy with ___ on ___ pathology showing
inflammation consistent with autoimmune hepatitis and toxic
metabolic injury. MRCP showed ascites and varices without liver
mass. She was continued on ursodiol. Azathioprine was increased
to 125mg daily. Prednisone was started for autoimmune hepatitis
at 40mg on ___ with concurrent bactrim prophylaxis and
calcium/vitamin d supplementation. Her ascites was managed with
3L removed by paracentesis with ___ on ___. When renal function
stabilized she was restarted on furosemide 20mg, spironolactone
50mg. She was given furosemide 40mg IV for diuresis during her
stay due to lower extremity edema and then transitioned back to
home dosing of oral furosemide. There was no evidence of SBP 118
WBC on diagnostic para ___. She was continued on nadolol.
# Pneumonia, suspected community acquired bacterial: Most likely
due to pulmonary etiology from CAP/Bronchitis. CXR showed
possible consolidation in LLL. Chest ct showed bronchial wall
thickening and opacities that may reflect pneumonia. She was
started on levoquin ___ and spiked fever to 101. She was
switched to ceftriaxone and azithromycin ___ with no further
fevers. Urine legionella antigen negative. CMV VL was negative.
EBV VL, mycoplasma antibodies, quantiferon gold pending at the
time of discharge. Ceftriaxone/azithromycin transitioned to
levoquin on ___ for a planned two week course to complete
___.
# ___: Recent baseline Cr 0.6. Presented with ___ to 0.9 with
hyponatremia with a history of recent flu like illness with GI
component. Alternatively, she has signs of worsening cirrhotic
physiology with worsening abdominal distention now with
improving creatinine s/p 62.5g albumin. Feurea: 3.5%, FeNa 0.42%
suggestive of pre-renal etiology. Restarted Furosemide and
spironolactone without renal impairment.
TRANSITIONAL ISSUES
=============
#NEW MEDICATIONS
- Vitamin D ___ UNIT PO 1X/WEEK (TH) for total of 12 weeks.
- Levofloxacin 750 mg PO DAILY (LAST DOSE ___
- PredniSONE 40 mg PO DAILY
- Sulfameth/Trimethoprim SS 1 TAB PO DAILY
- Calcium Carbonate 500 mg PO BID
#CHANGED MEDICATIONS
- AzaTHIOprine 125 mg PO/NG DAILY
- Ursodiol 500 mg PO BID
#STOPPED MEDICATIONS
- Alendronate Sodium 70 mg PO QSAT
- Budesonide 6 mg PO DAILY (patient was not taking) - please
avoid in the future as it puts patient at risk for thrombosis
- Ocaliva (obeticholic acid) 5 mg oral DAILY (patient was not
taking)
- Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
[ ] Added prednisone and increased dose of azathioprine for
autoimmune hepatitis. Monitor for response on prednisone and
increased dose of azathioprine. MELD 18 on day of discharge. If
not improving, then discuss liver transplant (workup started
inpatient)
[ ] Continue prednisone course for autoimmune hepatitis with
Bactrim prophylaxis
[ ] Labs for transplant workup were ordered while inpatient
[ ] She asked about the possibility of live donor as well
[ ] Multiple side-branch IPMN will require follow up imaging
[ ] Follow up chest CT to document resolution of opacities after
treatment with antibiotics
[ ] Optimize diuretics to balance relative hypotension and
worsening ascites. Low blood pressures prevented increasing
dosing while inpatient.
[ ] Continue ergocalciferol 50,000 units weekly for total of 12
weeks for low vitamin D. Switch to ___ units daily after
completion of weekly doses
[ ] Alendronate stopped because it puts her at risk for
esophagitis and bleeding from esophageal varices. Please ensure
Endocrinology follow up to discuss alternative medications
[ ] Ensure she is taking in no alcohol, including with cooking
[ ] Follow up repeat quantiferon gold as first was
indeterminate. If repeat is indeterminate will need further
workup.
# CODE: Full code, confirmed
# CONTACT: ___ (boyfriend) ___
# DISCHARGE WEIGHT: 69.13 kg |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
shellfish
Attending: ___.
Chief Complaint:
Fall from 25ft roof
Major Surgical or Invasive Procedure:
1. Right femur ORIF ___, ___
2. Left wrist ORIF ___, ___
History of Present Illness:
___ w/ no signficant PMHx fell off roof this morning and
suffered open R femur fracture. He slipped on frozen piece of
roof and fell 25' to ground, landing on his R side. He denies
LOC. Reports headache and pain on R chest wall, R leg. Open
fracture w/ exposed femur noted by EMS and pt placed in traction
splint. Brought to ___ where he recieved Ancef,
tetanus. He has remained alert and oriented. Denies weakness,
numbness in RLE. Denies other extremity pain.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
Boarded & collared, RLE traction splint in place. A&Ox3, GCS 15
Vitals: afebrile, VSS
Right upper extremity:
Skin intact
Soft, non-tender arm and forearm
Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Left upper extremity:
Skin intact
Ecchymosis, mild swelling, TTP over distal radius. Mild pain w/
ROM at wrist.
Full, painless AROM/PROM of shoulder, elbow, digits
+EPL/FPL/DIO (index) fire
+SILT axillary/radial/median/ulnar nerve distributions
+Radial pulse
Right lower extremity:
Open fracture of distal femur w/ exposed bone, appear anteriorly
dislocated. 5cm skin laceration overlying fracture.
Soft thigh and leg
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Left lower extremity:
Skin intact
Soft, non-tender thigh and leg
Full, painless AROM/PROM of hip, knee, and ankle
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 07:33PM WBC-11.6* RBC-4.78 HGB-13.7* HCT-40.5 MCV-85
MCH-28.6 MCHC-33.7 RDW-13.0
___ 07:33PM PLT COUNT-185
___ 09:09AM COMMENTS-GREEN TOP
___ 09:09AM GLUCOSE-138* LACTATE-2.1* NA+-138 K+-3.5
CL--106 TCO2-23
___ 09:08AM UREA N-13 CREAT-0.8
___ 09:08AM estGFR-Using this
___ 09:08AM LIPASE-38
___ 09:08AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:08AM WBC-11.5* RBC-5.54 HGB-15.2 HCT-45.9 MCV-83
MCH-27.4 MCHC-33.1 RDW-12.5
___ 09:08AM PLT COUNT-174
___ 09:08AM ___ PTT-29.1 ___
___ 09:08AM ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain, Fever
2. Cephalexin 500 mg PO Q6H Duration: 6 Days
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Open right distal femur fracture s/p I&D and ORIF
2. Left distal radius fx/ scaphoid fx/ scapholunate widening s/p
ORIF
3. Right metatarsal & ___ phalanx fractures
4. Facial laceration s/p suture repair by plastics
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Fall from height. Chest wall tenderness bilaterally. Open femur
fracture.
TECHNIQUE: Contiguous axial images of the torso were obtained following the
uneventful administration of 130 cc Omnipaque intravenous contrast. Coronal
and sagittal reformations were obtained.
DLP: 585 mGy-cm
CTDIvol: 9 mGy
COMPARISON: None available.
FINDINGS:
Lungs: The thyroid is normal. No axillary, hilar, or mediastinal
lymphadenopathy. The heart and great vessels are grossly normal and there is
no pericardial effusion or aortic pathology. Minimal right pneumothorax. Old
left 4th rib fracture is identified. No other rib fractures are seen.
Bilateral dependent atelectasis is noted, otherwise the lungs are clear with
no effusions, consolidations, or nodules. The esophagus is normal with no
hiatal hernia.
Abdomen: The liver enhances homogeneously with a hypodensity in segment 4A
measuring 10 mm, likely a cyst or biliary hamartoma. There is no intra or
extrahepatic biliary dilatation and the portal veins are patent. The
gallbladder is normal with no radiopaque stones or pericholecystic fluid. The
pancreas is normal with no peripancreatic fat stranding. The spleen enhances
homogeneously with no focal lesions. The adrenal glands are normal in size
and morphology. The kidneys enhance symmetrically with no focal lesions or
hydronephrosis. There is symmetric contrast excretion. The stomach, small
bowel, and large bowel is normal in caliber with no evidence of obstruction.
The appendix is normal. No intra-abdominal free air or free fluid. No
mesenteric or retroperitoneal lymphadenopathy.
Pelvis: The bladder is well distended and normal appearing. The prostate and
seminal vesicles are normal. No pelvic free fluid. No pathologically
enlarged pelvic sidewall or inguinal lymphadenopathy.
Vessels: The abdominal aorta is normal in caliber. The aorta and its major
branches are patent.
Bones: No blastic or lytic lesions suspicious for malignancy or infection.
No thoracolumbar spine or pelvic fractures.
IMPRESSION:
1. Tiny right pneumothorax.
2. Old left 4th rib fracture. No other thoracic or abdominal injuries
identified.
Radiology Report
HISTORY: 25 ft fall with nose injury.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal and sagittal
and thin section bone algorithm-reconstructed images were acquired.
DLP: 891 mGy-cm.
CTDIvol: 48 mGy.
COMPARISON: None available.
FINDINGS:
There is no hemorrhage, mass effect or midline shift, edema, or infarct. The
ventricles and sulci are normal in size and configuration. The basal cisterns
are patent and there is normal gray-white matter differentiation.
Comminuted, depressed bilateral nasal bone and frontal process of the maxilla
fractures are noted. The bony nasal septum is also fractured distally. Mucosal
thickening in the right maxillary sinus and ethmoid air cells bilaterally are
mild. Otherwise, the paranasal sinuses, mastoid air cells and middle ear
cavities are clear.
IMPRESSION:
Comminuted bilateral nasal bone, frontal process of the maxilla, and bony
nasal septum fractures. No other acute process.
Radiology Report
HISTORY: 25 ft fall with facial injury. Evaluate for traumatic injury.
COMPARISON: None available.
Technique: Contiguous axial images of the cervical spine were obtained without
intravenous contrast. Coronal, sagittal, and bone algorithm formatted images
were obtained.
DLP: 729 mGy-cm.
CTDIvol: 37 mGy.
FINDINGS:
There is no fracture or traumatic malalignment. The prevertebral soft tissues
are normal. No significant degenerative changes are noted. Evaluation of the
aerodigestive tract is unremarkable. Lung apices demonstrate minimal right
apical pneumothorax. The soft tissues of the neck are normal.
IMPRESSION:
Minimal right apical pneumothorax. No cervical spine fracture or traumatic
malalignment.
Radiology Report
HISTORY: Open right femur fracture after 25 foot fall.
TECHNIQUE: Right femur, 2 views, right knee, 2 views and right tibia and
fibula, 2 views.
COMPARISON: None.
FINDINGS:
Comminuted open fracture of the distal femoral diaphysis is noted with dorsal
displacement of the dominant distal fracture fragment by approximately ___
shaft width. The fracture line extends to involve the lateral femoral condyle
and articular surface with slight widening of the lateral joint space. There
is extensive subcutaneous gas and soft tissue swelling about the fracture site
with subcutaneous gas noted tracking along the medial aspect of the thigh.
Air is also noted within the suprapatellar recess. No other fracture or
dislocation is identified. The ankle mortise appears symmetric. The talar
dome is smooth.
IMPRESSION:
Open comminuted fracture of the distal femoral diaphysis with extension to the
lateral femoral condyle and articular surface.
Radiology Report
HISTORY: Open fracture of the right femur.
TECHNIQUE: AP view of the pelvis.
COMPARISON: CT abdomen and pelvis obtained the same day.
FINDINGS:
There is no acute fracture or dislocation. Hips and sacroiliac joints are
preserved. No diastasis of the pubic symphysis is noted. Contrast is seen
within the bladder from recent CT exam.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
HISTORY: Open fracture of the right femur.
TECHNIQUE: Right foot, 2 views.
COMPARISON: None.
FINDINGS:
Assessment of the left foot is somewhat limited by an overlying external
fixator device and lack of an oblique projection. Given these limitations,
there appears to be an oblique linear lucency involving the base of the
proximal phalanx of the ___ toe as well as the head of the ___ metatarsal,
which could reflect non-displaced intra-articular fractures. No dislocation
is identified. Assessment of the calcaneus is limited.
IMPRESSION:
Limited exam. Possible intra-articular fractures involving the base of the
___ proximal phalanx and head of the ___ metatarsal.
Radiology Report
HISTORY: Fall from height with facial laceration. Evaluate for facial bone
fractures.
TECHNIQUE: Contiguous axial images through the facial bones were obtained
without intravenous contrast. Coronal, sagittal, and bone algorithm were
formatted images were obtained.
DLP: 488 mGy-cm
CTDIvol: 26 mGy
COMPARISON: None available.
FINDINGS:
There are bilateral comminuted fractures of the nasal bones, frontal processes
of the maxilla, and the bony nasal septum. There is associated soft tissue
swelling around the nose and mucosal thickening in the ethmoid sinuses and
right maxillary sinus. No other facial bone fractures identified. Mastoid
air cells are well aerated. Periapical lucencies are noted in several
maxillary teeth. Additionally, dental caries are seen in multiple maxillary
and mandibular teeth. The deep soft tissues of the face are normal.
Evaluation of the aerodigestive tract is unremarkable.
IMPRESSION:
1. Comminuted bilateral nasal bone, frontal processes of the maxilla, and
bony nasal septum fractures with associated soft tissue swelling.
2. Periodontal disease and dental caries of several mandibular and maxillary
teeth.
Radiology Report
HISTORY: Fall with left wrist pain and swelling over the distal radius.
TECHNIQUE: 4 views of the left wrist.
COMPARISON: None.
FINDINGS:
Longitudinally oriented fracture through the distal radius with
intra-articular extension is noted with approximately 4 mm of medial
displacement of the medial fracture fragment. There is widening of the
scapholunate interval and there is a linear lucency through the waist of the
scaphoid concerning for a nondisplaced fracture. Additionally a tiny osseous
fragment is noted dorsally on the lateral view, suspicious for triquetrial
fracture. No dislocation is identified. There is diffuse soft tissue
swelling.
IMPRESSION:
1. Mildly displaced distal radial fracture with intra-articular extension.
2. Triquetrial fracture.
3. Widening of the scapholunate interval suggests ligamentous injury with
nondisplaced fracture through the waist of the scaphoid.
Radiology Report
HISTORY: Fracture fixation.
10 intraoperative radiographs of the right distal femur are obtained during
placement of a lateral plate and multiple screws across the markedly
comminuted distal femoral fracture (as shown on images from seven hours
earlier on same day). There are several additional interfragmentary screws.
Radiology Report
HISTORY: Fracture reduction.
A single AP bedside radiograph of the left wrist again shows the widened
scapholunate space suggesting ligamentous injury. The unusual vertical
intra-articular fracture of the distal radius seen exam 6 hour previous is not
identified, which may reflect fracture reduction or simply positioning.
Radiology Report
INDICATION: Left carpal fractures, CT scan to evaluate fractures.
TECHNIQUE: Axial MDCT images were acquired through the wrist without
intravenous contrast. Coronal and sagittal reformats were produced and
reviewed.
COMPARISON: Left wrist radiograph ___.
FINDINGS:
Images were obtained in a cast. There is a vertically oriented fracture
through the distal radius with intra-articular extension (___). This
disrupts the articular surface by approximately 1.3 mm.
There is widening of the scapholunate interval measuring 6mm (500B:41),
concerning for injury to the scapholunate ligament. The ligament itself
cannot be visualized on this study, due to limitations of the modality.
There is a subtle linear lucency throught the waist of the scaphoid which is
only visualized on the sagittal reformats (501b:38). The apperances are
concerning for a non-displaced scaphoid waist fracture.
There is a tiny oblique fracture of the dorsal aspect of the triquetrum
(501B:59). The donor site is also seen at this level.
There are very mild degenerative changes at thumb carpometacarpal joint
(500B:29).
There is diffuse subcutaneous edema. Possible small wrist effusion. The
tendons of the carpal tunnel are within normal limits given the limitations of
the imaging technique.
IMPRESSION:
1. Vertically oriented fracture of the distal radius with intra-articular
extension and disruption of the articular surface by 1.3 mm.
2. Small fracture at the dorsal aspect of the triquetrum.
3. Apparent widening of the scapholunate interval, concerning for
scapholunate ligament injury.
4. Subtle linear lucency in the waist of the scaphoid concerning for an
non-displaced fracture. No radiographic correlate is identified, though this
difference could reflect increased sensitivity for CT.
The pertinent findings were posted to the critical results dashboard at 5pm on
___.
Radiology Report
HISTORY: Left wrist pain, question fracture.
LEFT WRIST, THREE VIEWS.
COMPARISON: Left wrist radiographs from ___.
Cast is in place, obscuring fine bony detail. Allowing for this, there is
scapholunate widening measuring up to 6.1 mm. Again seen is the longitudinal
fracture subtending the ulnar aspect of the distal radius, extending to the
articular surface, with very mild depression of the ulnar fragment. Alignment
is otherwise anatomic. The subtle fracture line through the scaphoid waist
identified on today's CT scan is not definitely visualized, as there is
overlying artifact related to the cast.
Radiology Report
INDICATION: Open fracture status post ORIF, question of fever, pneumonia.
COMPARISON: None available.
FINDINGS: AP view of the chest. Low lung volumes. There is no focal
consolidation, pleural effusion, or pneumothorax. The cardiomediastinal and
hilar contours are normal.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old man polytrauma, fall ___ w/ open femur fx ___ s/p
ORIF, w/ tachy+ SOB + chest pain at rest. // Rule out PE
TECHNIQUE: MDCT data were acquired through the chest after the uneventful
administration of intravenous contrast. Images were displayed in two axial
slice thicknesses and multiple planes including oblique maximum intensity
projections.
DOSE: DLP: 191 mGy cm
COMPARISON: Chest radiograph earlier today
FINDINGS:
CTPA: The pulmonary arterial tree is well opacified to the subsegmental level.
There is no pulmonary embolism or other filling defect. The main pulmonary
artery is not enlarged. The aorta and proximal great vessels have normal
caliber and appearance. There is no aneurysm or dissection. There are no
coronary artery or aortic arch calcifications.
CT CHEST: The lungs are well expanded and clear. There is a 5 mm solid nodule
identified in the left upper lobe (06:35, 8:43) There is no focal
consolidation, effusion, or pneumothorax. Airways are patent to the
subsegmental level. The thyroid enhances homogeneously. There is no
mediastinal, hilar, or axillary adenopathy. The size of the heart is normal.
There is no pericardial effusion. A tiny right pneumothorax is unchanged.
This exam is not tailored to evaluate the intra-abdominal structures.
Visualized portions of the upper abdomen show no abnormality.
There are no concerning osseous lesions.
IMPRESSION:
1. No pulmonary embolism
2. 5 mm left upper lobe nodule. As per the ___ Pulmonary Nodule
Guidelines, followup chest CT is recommended in 12 months for a low risk
patient and ___ months for a high risk patient.
3. Tiny right pneumothorax unchanged.
Radiology Report
CLINICAL HISTORY: Fracture of scaphoid with scapho/lunate widening,
intraoperative repair.
Vertical fracture of the distal radius also.
Post-operative films.
Multiple pins are seen through the scaphoid and other carpal bones. Screws
and plate are present along the distal radius. The alignment appears good.
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show placement of multiple fixation
devices about fractures of the scaphoid and distal radius. Further
information can be gathered from the operative report.
Radiology Report
HISTORY: ORIF.
FINDINGS: In comparison with the operative study of ___, there is little
change in the appearance of the extensive fixation device about the long
comminuted and apparently intra-articular fracture of the distal tibia. No
evidence of hardware-related complication. Little if any callus formation is
appreciated.
Gender: M
Race: SOUTH AMERICAN
Arrive by HELICOPTER
Chief complaint: 25"FALL
Diagnosed with FX FEMUR NOS-OPEN, OTHER FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right open midshaft femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right femur I7D and ORIF, which
the patient tolerated well (for full details please see the
separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor.
Musculoskeletal: Prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT RLE. Throughout the hospitalization,
patient worked with physical therapy, who determined that
discharge to home with home ___ was most appropriate. His left
upper extremity remains NWB in a splint post-op. Two week
post-op films were obtained on ___ and staples were removed.
Neuro: Post-operatively, patient's pain was controlled by
dilaudid PCA and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood for acute
blood loss anemia.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD ___, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. He will follow up in 4 weeks post-discharge, as
his two week follow up was done while he was in house. The
patient completed his two week course of chemical DVT
prophylaxis. All questions were answered prior to discharge and
the patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal MRI finding
Recent diagnosis of cirrhosis and HCV
Major Surgical or Invasive Procedure:
Upper endoscopy (___)
Packed red blood cell transfusion (1 unit on ___
History of Present Illness:
Mr. ___ is a ___ with history of Wilms Tumor s/p
chemo/XRT and nephrectomy at age ___, recently diagnosed HCV
genotype 1, and chronic EtOH use, referred to ___ for
evaluation of new cirrhosis and possible IVC occlusion seen on
outpatient MRI.
He has had anemia for about ___ years, which has been slowly
worsening per outpatient labs. This was initially thought to be
secondary to iron deficiency but he took oral iron supplements
with no effect. Recently Hct was ~25 at PCP, down from ~30 in
___. He has noticed increasing fatigue which has correlated
with his declining hematocrit. He describes difficulty climbing
up the hill to get to his house in ___, and needs to rest
several times on the way. He remains able to walk ___ miles on
flat ground. He was formerly able to work 11 hour shifts as a
___ but recently has had to take time off due to
fatigue.
He has also been experiencing ~2 months of abdominal discomfort,
bloating, gassiness, and increasingly diarrhea, though in
retrospect the diarrhea may have started as long as ___ years ago.
Over the past months his daily bowel frequency has increased
from ~3 bowel movements a day to ___ loose bowel movements a
day. He saw his PCP ~1 month ago, where labs were notable for
mildly elevated transaminases (he had a history of transamnitis
to ~3x upper limit of normal dating back to ___ and positive
HCVAb. He was referred to Dr. ___, gastroenterologist.
Additional labs done recently showed elevated ALT/AST, normal
TBili and INR, AFP elevated to 17.8 and HCV titer ~970,000 IUs.
Per verbal report from outside providers, an MRI performed at
___ MRI on ___ in ___ showed cirrhotic
appearing liver, ascites, and 2 small enchancing lesions in
segment I and VI and possible splenorenal varices and possible
IV thrombosis. A colonoscopy was done ___ with normal
appearance, biopsies pending.
The patient also has history of daily ETOH ___ years. There were
periods of heavy daily Whiskey (~1 bottle/week) surrounding
breakup with his fiance, but until 1 month ago he had been
having 2 beers every evening. Since he learned of his HCV
diagnosis ___ weeks ago, he has not had any more alcohol.
Suspected source of HCV exposure is blood transfusion that he
received at age ___ at the time of his Wilms tumor resection at
___. No other transfusions.
In the ED, initial vital signs were: 98.7, 95, 117/81, 18, 100%
RA.
Initial labs were significant for AST/ALT of 93/41, Albumin 2.7,
Hct 22. Abdominal ultrasound was notable for echogenic liver
consistent with cirrhosis, mild to moderate ascites without
easily accessible pocket for drainage, cholelithiasis, and no
ultrasound evidence of IVC thrombosis or hepatic lesions. CXR
showed small right pleural effusion.
The patient received no medications in the ED and was
transferred to the general medical floor for further management.
On arrival to the floor, patient reports no acute complaints.
Review of Systems:
Positive for: Increasing fatigue and windedness on exertion.
Chills, increasing ___ edema and abdominal girth, chronic
dyspnea, recent cough. Also has left ankle rash for months, and
recent "ringworm" on stomach.
(-) Denies fever. Denies chest pain or tightness, palpitations.
Denies wheezes. Denies dysuria, stool or urine incontinence.
Denies arthralgias or myalgias. No numbness/tingling in
extremities. All other systems negative. No hematemesis, melena,
hematochezia.
Past Medical History:
- Nephrectomy at age ___ followed by chemotherapy and radiation
for Wilms tumor. Question of spread to heart, requiring
sternotomy and heart surgery.
- Hypothyroidism after total thyroidectomy for cysts seen ___
years ago which were concerning given his history of radiation.
- Possible asthma
- Bronchiectasis
- Pulmonary nodule
- +asbestos exposure at theater where he worked
Social History:
___
Family History:
Paternal grandfather and aunt with brain tumor.
Maternal relatives with heart disease and stroke.
No known family history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.6 112/60 73 18 100RA
GEN: Pale appearing man seated in bed in NAD, pleasant and
conversant
HEENT: Sclera anicteric, conjunctiva pale. MMM, oropharynx
clear.
Neck: Supple. No JVD, no LAD. Thyroidectomy scar noted.
Chest: RRR, S1/S2, no m/r/g. Median sternotomy scar noted. Mild
gynecomastia.
Lungs: Clear to auscultation bilaterally
Abdomen: Minimally tender, no rebound/guarding, mildly
distended, normoactive BS. Tympanic to percussion at apex, dull
at bases.
Ext: Warm/well perfused. Trace ___ edema.
Neuro: AAOx3. No asterixis.
Skin: No jaundice. Brown hyperpigmented spots on medial surface
of left foot. No spider angiomata, no caput medusa, no palmar
erythema.
DISCHARGE PHYSICAL EXAM:
98.7 98.4 109-123/60s 76 18 99RA
GEN: Pale appearing man seated in bed in NAD, pleasant and
conversant
HEENT: Sclera anicteric, conjunctiva pale. MMM, oropharynx
clear.
Neck: Supple. No JVD, no LAD. Thyroidectomy scar noted.
Chest: RRR, S1/S2, no m/r/g. Median sternotomy scar noted. Mild
gynecomastia.
Lungs: Clear to auscultation bilaterally
Abdomen: Minimally tender, no rebound/guarding, mildly
distended, normoactive BS. Tympanic to percussion at apex, dull
at flanks.
Ext: Warm/well perfused. Trace ___ edema.
Neuro: AAOx3. No asterixis.
Skin: No jaundice. Brown hyperpigmented spots on medial surface
of left foot. No spider angiomata, no caput medusa, no palmar
erythema.
Pertinent Results:
IMAGING STUDIES
***Abdominal MRI performed at ___ ___
Comparison of in and out of phase imaging does not show
significant signal dropout to suggest fatty infiltration. Left
lobe of the liver appears somewhat prominent. There is somewhat
lobular reticulated pattern [sic] the hepatic parenchyma seen on
T1 imaging suggestive of diffuse liver disease, fibrosis and
cirrhosis. Early arterial imaging shows somewhat heterogeneous
patt4ern of enhancement. There are noted to be slightly more
prominent foci of enchancement seen in hepatic segment 1, please
see series 12 image 57 and in hepatic segment 6, please see
axial series 12 image 38. There are a few scattered
subcentimeter nonenhancing T2 hyperintensities within the right
lobe of the liver suggestive of cysts. The infrahepatic IVC is
not visualized and there are prominent right pararenal varices
as welll as paraspinal varices.
There is abdominal fluid, ascites. There is [sic] some areas of
soft tissue thickening around the liver, please see series 3
image 79, without enhancement which may represent adhesions.
Left kidney is not visualized consistent with provided history
of Wilms tumor, prior surgery as child. Right kidney appears
prominent, possibly at due to compensatory hypertrophy without
suspicious focal lesion. There does not appear to be enlargement
of the right adrenal gland although it is not well seen due to
patient motion. No suspicious splenic lesion is seen. No
suspicious pancreatic lesion is identified.
Impression:
Cirrhotic liver. Early arterial postcontrast imaging shows
heterogeneous hepatic enhancement with two slightly more
prominent foci of enhancement as described above; these findings
may be due to transient hepatic vascular differences however
continued surveillance is suggested.
Ascites.
Infra-hepatic IVC appears occluded and there are prominent
right-sided pararenal, paraspinal varices.
--- Informal review of the MRI images here revealed: ---
Nodular cirrhosis with ascites. Left nephrectomy. Right kidney
is hypertrophied. The spleen measures 9.3 cm, no evidence of
splenomegaly. There are two cysts/hamartomas in the right
hepatic lobe which are non-enhancing. There is a 9-10 mm area of
enhancement in the caudate but given no washout, is less
concerning for HCC. No clear evidence of IVC thrombosis.
Abd US with Duplex Doppler ___:
1. Coarsened liver may be due to fatty infiltration and/or
cirrhosis. Other more advanced forms such as fibrosis/cirrhosis
not excluded on this study.
2. No hepatic lesions are identified. However, MRI is more
sensitive for detection of small hepatic lesions.
3. Wall-to-wall color flow in the visualized IVC. No evidence of
IVC
thrombosis seen sonographically. Recommend correlation with
prior examinations when they become available or MRV/CTV.
4. Small amount of ascites.
5. Cholelithiasis with no evidence of acute cholecystitis.
6. Mild pelviectasis of the right kidney
CXR ___:
Small right pleural effusion.
LABORATORY RESULTS
___ 12:41PM BLOOD WBC-5.8 RBC-1.94* Hgb-6.5* Hct-22.0*
MCV-114* MCH-33.6* MCHC-29.6* RDW-17.3* Plt ___
___ 10:50AM BLOOD WBC-6.0 RBC-2.17* Hgb-7.6* Hct-23.8*
MCV-109* MCH-35.0* MCHC-32.0 RDW-18.5* Plt ___
___ 12:41PM BLOOD Neuts-52.4 ___ Monos-7.5 Eos-6.1*
Baso-0.5
___ 10:50AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
Burr-OCCASIONAL
___ 12:41PM BLOOD ___ PTT-38.5* ___
___ 10:50AM BLOOD ___ PTT-46.7* ___
___ 12:41PM BLOOD Glucose-79 UreaN-14 Creat-1.0 Na-136
K-4.1 Cl-109* HCO3-19* AnGap-12
___ 10:50AM BLOOD Glucose-88 UreaN-15 Creat-1.0 Na-136
K-4.4 Cl-109* HCO3-19* AnGap-12
___ 12:41PM BLOOD ALT-41* AST-93* AlkPhos-96 TotBili-0.3
___ 10:50AM BLOOD ALT-37 AST-82* AlkPhos-85 TotBili-0.9
___ 10:50AM BLOOD Calcium-7.5* Phos-3.0 Mg-1.7
___ 12:41PM BLOOD Albumin-2.7*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. milk thistle 140 mg oral Daily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
5. milk thistle 140 mg oral Daily
6. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
7. Outpatient Lab Work
Please check Na, K, Cl, HCO3, BUN, Cr, Ca, Phos, Mg, CBC on
___. (ICD-9 code: ___)
Fax results to: ___ MD [Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
HCV cirrhosis
Esophagitis
Chronic macrocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: History: ___ with hep C p/w ascites and ? occluded IVC // eval
for flow, cirrhosis, ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver demonstrates coarsened echotexture. There is no focal liver
mass identified. Main portal vein is patent with hepatopetal flow. There is
mild to moderate moderate abdominal ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm.
GALLBLADDER: The gallbladder is collapsed with a few gallstones seen.
Cholecystitis.
PANCREAS: Pancreas is partially obscured by bowel gas, but visualized portion
is unremarkable.
SPLEEN: Normal echogenicity, measuring 10.2 cm.
KIDNEYS: The right kidney measures 13.7 cm. The left kidney is surgically
absent. Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There are no masses or stones in the right kidney. There is
mild pelviectasis seen in the right kidney.
RETROPERITONEUM: There is wall to wall color flow in the visualized IVC.
There is no evidence of IVC thrombosis.
IMPRESSION:
1. Coarsened liver may be due to fatty infiltration and/or cirrhosis. Other
more advanced forms such as fibrosis/cirrhosis not excluded on this study.
2. No hepatic lesions are identified. However, MRI is more sensitive for
detection of small hepatic lesions.
3. Wall-to-wall color flow in the visualized IVC. No evidence of IVC
thrombosis seen sonographically. Recommend correlation with prior examinations
when they become available or MRV/CTV.
4. Small amount of ascites.
5. Cholelithiasis with no evidence of acute cholecystitis.
6. Mild pelviectasis of the right kidney.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with hep c and abdominal pain // eval infiltrate
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are relatively hyperinflated. No focal consolidation is seen. There
is blunting of the right costophrenic angle consistent with a small right
pleural effusion. The cardiac and mediastinal silhouettes are unremarkable.
The patient is status post median sternotomy with the inferior-most wire
possibly fractured. Multiple surgical clips are noted in the upper abdomen.
IMPRESSION:
Small right pleural effusion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ASCITES
Diagnosed with CIRRHOSIS OF LIVER NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA
temperature: 98.7
heartrate: 95.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 81.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ with history of Wilms Tumor s/p
chemo/XRT and nephrectomy at age ___, recently diagnosed HCV
genotype 1, and chronic EtOH use, referred to ___ for
evaluation of new cirrhosis and possible IVC occlusion seen on
outpatient MRI.
# Cirrhosis: Newly diagnosed, likely secondary to HCV and
alcohol use. MELD score 10 based on age and admission labs.
Outside MRI report initially concerning for ___ but hepatic
lesions are not classic for ___ on our review of images here. No
history of hepatic encephalopathy. We initiated diuresis with
furosemide. Nutrition was consulted for education regarding low
sodium diet. A 2L fluid restriction was placed. He had a
screening endoscopy which revealed no varices but was notable
for esophagitis, for which PPI was started.
# Ascites: New onset ascites, no history of paracentesis. This
was evaluated with ultrasound but no readily accessible fluid
pocket was seen, so paracentesis was deferred. There was low
suspicion for SBP in the absence of SIRS/sepsis physiology or
abdominal pain.
# Hepatitis C: Genotype 1, untreated. Will follow-up outpatient
records. ___ need to consider treatment in the future.
# Coagulopathy: INR 1.4 on admission, no known source of
bleeding but had Hgb 6.5 in the setting of untreated hepatitis
C. Plt 158. We administered Heparin SC given platelet count was
in the normal range.
# Anemia: Hct slowly downtrending since ___. He is symptomatic
with fatigue and decreased exercise tolerance. Hct 22.0 (Hgb
6.5) on admission, and macrocytic (MCV 114), likely etiologies
include ETOH toxicity vs HCV marrow suppression vs nutritional
deficiency. He was transfused 1 unit pRBCs and tolerated this
well with appropriate increase in post-transfusion hematocrit.
# Hypothyroidism: Continued home levothyroxine.
# Asthma: Continued home albuterol inhaler. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / amiodarone
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old man with atrial fibrillation,
non-ischemic cardiomyopathy with EF 45% with hx of VT s/p ICD
placement who presented with fevers and malaise, admitted from
the ED due to hypotension and concern for sepsis.
Patient was recently hospitalized at ___ in ___ and ___
for fevers and rigors, found to have Strep infantarius
bacteremia ___ bottles). Per the ID outpatient note, "The
portal of entry of the strep infantarius bacteremia remained
unclear, as Strep infantarius is part of the strep bovis species
(type II bovis), commonly associated with the GI tract, but may
be implicated by more upper GI, hepatobiliary origin rather than
the lower colonic of strep gallolyticus (type I bovis). TEE
without evidence of endocarditis or vegetation on ICD lead." He
was treated with a 6 week course of CTX, finished in ___
Now, the patient reports a 1 day history of decreased appetite,
fevers, and weakness. Overnight, he was unable to get out of bed
to use the restroom due to weakness (uses cane at baseline). He
checked his temperature overnight as he was feeling feverish,
and found it to be 100.8F. Did feel briefly dyspneic while lying
in bed this AM, but denies chest pain or cough. Similarly no
sore throat, palpitations, abdominal pain, diarrhea, dysuria, or
increased urinary frequency.
In the ED, initial vitals: 101.9 60 112/49 18 97% RA.
Labs notable for: H/H 11.9/37.7. PLT 93. Cr of 1.3 (baseline of
1.0-1.1). Lactate 2.0. FLU A/B negative. UA notable for PROT 30
but negative for ___.
Imaging: CXR was negative for pneumonia.
Patient received:
___ 09:31 PO Acetaminophen 1000 mg
___ 09:50 IVF NS 500 mL
___ 11:10 IV Vancomycin (1000 mg ordered)
___ 11:15 IV CefTRIAXone 1 gm
Consults: no consults were requested.
Vitals on transfer: 69 87/62 16 98% RA
Upon arrival to ___, patient endorsed the above story.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- s/p ICD
3. OTHER PAST MEDICAL HISTORY
Permanent atrial fibrillation c/b CVA (___)
Monomorphic ventricular tachycardia, s/p ICD in ___
h/o CVA
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. Brother had isolated episode of a fib.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.6, HR 74, BP 93/65, Sat 97% on RA
GENERAL: Pleasant, alert and interactive. NAD.
HEENT: Sclera anicteric, PERRL, MMM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: No increased work of breathing. Left basilar crackles,
but lungs otherwise clear. No wheezes or rales.
CV: Irregularly irregular rhythm, Audible S1 and S2. Faint
systolic murmur best heard at apex.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No visible rashes or other lesions.
NEURO: A&Ox3 + situation. Moving all 4 extremities. No visible
facial asymmetry.
ACCESS: PIVx2
DISCHARGE PHYSICAL EXAM:
___ 0502 Temp: 97.6 PO BP: 115/77 L Lying HR: 70 RR: 18 O2
sat: 97% O2 delivery: Ra
GENERAL: NAD, appears younger than stated age
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
no
oral lesions
HEART: irregular rhythm, normal rate, systolic murmur throughout
precordium
LUNGS: bibasilar crackles and coarse breath sounds without
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 1+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS:
===============
___ 09:10AM BLOOD WBC-8.1 RBC-4.26* Hgb-11.9* Hct-37.7*
MCV-89 MCH-27.9 MCHC-31.6* RDW-14.3 RDWSD-45.5 Plt Ct-93*
___ 09:10AM BLOOD Neuts-88.7* Lymphs-3.7* Monos-6.4
Eos-0.4* Baso-0.2 Im ___ AbsNeut-7.18* AbsLymp-0.30*
AbsMono-0.52 AbsEos-0.03* AbsBaso-0.02
___ 01:54AM BLOOD ___ PTT-37.4* ___
___ 09:10AM BLOOD Glucose-102* UreaN-31* Creat-1.3* Na-139
K-5.1 Cl-102 HCO3-23 AnGap-14
___ 09:10AM BLOOD ALT-18 AST-27 LD(LDH)-245 AlkPhos-98
TotBili-0.7
___ 09:10AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.2 Mg-1.9
___ 12:17AM BLOOD ___ pO2-44* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
RELEVANT LABS:
==============
___ 09:10AM BLOOD proBNP-5811*
___ 09:33AM BLOOD Lactate-2.0
MICROBIOLOGY:
=============
Urine culture - negative
Blood cultures - NGTD
___ 1:10 pm Rapid Respiratory Viral Screen & Culture
Site: NASOPHARYNX Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
RELEVANT IMAGING:
=================
___ CXR
IMPRESSION:
No evidence of pneumonia. Small right pleural effusion.
___ CXR
IMPRESSION:
Increased opacities in the left lower lung possibly reflective
of lower
pleural fluid and overlying atelectasis/consolidation.
DICHARGE LABS:
==============
___ 06:18AM BLOOD WBC-8.5 RBC-4.25* Hgb-11.7* Hct-37.7*
MCV-89 MCH-27.5 MCHC-31.0* RDW-14.6 RDWSD-46.2 Plt ___
___ 06:18AM BLOOD Glucose-98 UreaN-35* Creat-1.2 Na-141
K-4.2 Cl-101 HCO3-26 AnGap-14
___ 06:18AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.4
Radiology Report
INDICATION: History: ___ with fever, dyspnea*** WARNING *** Multiple patients
with same last name!// ? pneumonia
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph dated ___. Chest CT dated ___.
FINDINGS:
Left-sided pacer with its lead terminating in the right ventricle is in
unchanged position. There is bibasilar atelectasis. No focal consolidation
to suggest pneumonia. No pulmonary edema. There is small right pleural
effusion. No pneumothorax. Moderate cardiomegaly persists. Mediastinal
silhouette is unremarkable. No acute osseous abnormalities.
IMPRESSION:
No evidence of pneumonia. Small right pleural effusion.
Radiology Report
INDICATION: ___ year old man with new onset sob and wheezing// ?consolidation,
pleural effusions
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A left chest wall single lead AICD is present. The size of the cardiac
silhouette is markedly enlarged unchanged. Retrocardiac opacities are
increased since prior and may reflect atelectasis and/or consolidation. A
layering pleural effusion is also suspected. There is no pneumothorax. No
focal consolidation within the right lung.
IMPRESSION:
Increased opacities in the left lower lung possibly reflective of lower
pleural fluid and overlying atelectasis/consolidation.
Radiology Report
INDICATION: ___ year old man with Afib, HTN, recent strep infantarius
bacteremia, presenting with fevers and hypotension. Run of VT overnight, now
with new basilar crackles// please assess for pulmonary edema, other interval
change
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Left-sided single lead pacemaker with the lead in the right ventricle.
Overall no changes prior. Moderate cardiomegaly. No pulmonary edema.
Unchanged retrocardiac opacities. No focal consolidation or pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Fever
Diagnosed with Sepsis, unspecified organism, Fever, unspecified, Bacteremia, Severe sepsis with septic shock, Dyspnea, unspecified
temperature: 101.9
heartrate: 60.0
resprate: 18.0
o2sat: 97.0
sbp: 112.0
dbp: 49.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is an ___ yo male with history of atrial fibrillation
on rivaroxaban, CVA, VT s/p ICD placement, prolonged QT recently
initiated on quinidine, non-ischemic cardiomyopathy (EF 45% -->
___, and hypertension with recent admission for Strep bovis
bacteremia s/p 6 wks CTX who presented to ___ on ___ with
fevers and hypotension initially treated in the ICU and then
transferred to the cardiology service with course c/b VT.
#Ventricular tachycardia
Patient ___ a complex history: Initial episode in ___. S/p
secondary prevention single chamber ICD. Recurrence in ___
w/MMVT that required ATP started on amiodarone 200 mg daily,
which was increased to 400 mg daily. Amio was later weaned due
to concern for a/e. Admitted in ___ with MMVT and EP applied
programmed ventricular stimulation via ICD with resolution of VT
and he was started on amiodarone IV, which was later d/c due to
previous intolerance. Underwent VT ablation on ___
readmitted with bacteremia and he was started on dofetaline,
however, his QTc was markedly prolonged on this regimen and so
it was discontinued. In follow up, he was started on quinidine
as his QT appeared shorter.
During this admission, the quinidine was held after QTC was
noted to be >500. After discontinuation of quinidine, the pt was
noted to have significant burden of VT while in the ICU. EP was
consulted. The patient was started on a lidocaine drip and then
transitioned to mexiletine 150 mg PO q 8 hours. His QTC remained
at 400 ms and he had no more episodes of VT.
#Heart failure with reduced ejection fraction
Patient ___ a history of non-ischemic cardiomyopathy with
reduced EF of 40-45%. Repeat echo during this admission
demonstrated worsening of EF ___. Unclear if this new
reduction is related to acute illness given fever and
hypotension upon admission vs. worsening burden of VT. Because
of his hypotension, his losartan and eplerenone was initially
held. This was restarted after his blood pressures improved. He
was given one dose of 40 mg IV Lasix on ___ given his increased
weight (we believe dry weight is 145-150 pounds) and elevated
proBNP. His metoprolol succinate was increased from 25 mg to 50
mg daily. Torsemide 5 mg was added upon discharge. Because of
reduced EF and symptoms, bIV pacer should be considered as an
outpatient.
#Hypotension/fevers
#Community acquired pneumonia
Pt presented with fever and hypotension concerning for sepsis.
Because of recent strep bovis bacteremia, ID was consulted.
Blood and urine cultures were without growth. Echo was without
vegetation. CXR was w/o consolidation although pt noted cough
upon admission. He was initially treated with vancomycin and
ceftriaxone for CAP, which was changed to ceftriaxone and
doxycycline to complete a five day course. With fluid
resuscitation and antibiotics, patient's symptoms improved and
he remained HDS.
#Thrombocytopenia
Pt was noted to have thrombocytopenia upon admission. No heparin
exposure. With treatment of sepsis, platelets increased and were
143 upon discharge.
#Severe MR
___ been evaluated for mitral clip in the past and sx not
thought to be related to severe MR. ___ consider re evaluation
for mitral clip as an outpatient.
#Atrial fibrillation with history of CVA
Patient was continued on home rivaroxaban and metoprolol
succinate was increased to 50 mg daily.
#Psych
Continued home lorazepam and mirtazapine
**TRANSITIONAL ISSUES** |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Amoxicillin / Cephalosporins / benzonate
Attending: ___.
Chief Complaint:
Cough and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CLL/SLL with pulmonary parenchymal
involvement diagnosed in ___ s/p chemotherapy (last in ___
c/b hypogammaglobulinemia on monthly IVIG and recurrent
PNA,bronchiectasis, chronic systolic heart failure (LVEF 40-45%
in___), and atrial fibrillation on rivaroxaban (TIA while
onwarfarin) who presents with subacute progressively worsening
cough and SOB and new hypoxia.
Patient reports that several weeks ago, he developed nocturnal
wheezing that would wake him from sleep, associated with
productive cough, chest congestion, orthopnea, and new dyspnea
on exertion. These symptoms felt similar to those he has had in
the past with lung infections. He used his albuterol nebs, which
helped somewhat. Of note, he also reports developing ___ edema
around this time, which is new for him.Patient presented to
primary care clinic on ___, at which timeCXR was unremarkable,
BNP was 100, and CBC and BMP were stable.He was treated with a
one-week course of prednisone for presumed asthma exacerbation.
Symptoms initially improved after tis course but then a few days
later, his dyspnea worsened, and he spiked a fever to 102.6
(___). He contacted his PCP over the phone and was prescribed
levofloxacin 500 mg x 10 d (now has 4 days left) and 5additional
days of prednisone (completed) without symptomatic relief.
He presented to clinic again today with persistent symptoms and
was noted to have hypoxia to 89% on RA so came toBIDMC.
In the ED, initial VS were notable for T 98.9, HR 96, BP
119/47,RR 18, SpO2 95% on 5L NC. (Patient notes he was febrile
to 102 inthe ED, but this was not recorded in the dash.)
Labs notable forCBC with WBC 11.5 (76.9% neutrophils, 15.9%
lymphocytes), Hgb11.7, platelets 168. BMP with Na 129, K 4.3,
bicarb 21, BUN 18,Cr 1.0. Lactate 1.5. EKG with LBBB.
CXR with opacities in the lung bases.
Received albuterol and ipratropium nebs and PO doxy100 mg.
Started on NSS at 75 cc/hr. Upon arrival to the floor, he
reports continued SOB/DOE and orthopnea. Denies chills, weight
loss, N/V, CP, arm/jaw pain,palpitations, abdominal pain,
diarrhea/constipation, hematochezia/melena, dysuria/increased
frequency/urgency, myalgias.
No history of blood clots, no recent prolonged
immobilization/travel.Of note, he was supposed to get IVIG today
for hypogammaglobulinemia; last got it 1 month ago as scheduled.
Past Medical History:
PAST ONCOLOGIC HISTORY:
CLL per HPI
PAST MEDICAL HISTORY:
1. SLL/CLL with pulmonary parenchymal involvement see HPI for
details
2. Chronic sinusitis with nasal polyp.
3. Hypogammaglobulinemia. Receives monthly IV IgG.
4. History of recurrent multifocal as well as aspiration
pneumonitis
5. Nonischemic cardiomyopathy. EF of 20% which has improved to
35-40% a few months ago. Last cardiac cath done at ___ in
___ showed normal coronary arteries.
7. Paroxysmal atrial fibrillation status post DC cardioversion,
on Coumadin.
8. Left bundle branch block.
9. History of SIADH during diuresis, requiring hypertonic
saline.
10. Chronic bronchiectasis.
11. History of H. influenzae in the sputum during admission at
___ in ___, is on chronic doxycycline
prophylaxis.
12. Mild to moderate intermittent asthma.
13. GERD/reflux esophagitis.
14. History of possible dysphagia and aspiration pneumonitis.
15. Colon polyps.
16. Thyroid nodule/possible hypothyroidism.
17. BPH.
18. Status post bronchoscopy in ___ showed CLL/SLL.
OTHER PMH per ___ records:
Asthma
THYROID NODULE
COLONIC ADENOMAS
Foot drop (uses brace)
plantar fasciitis, right
Rotator cuff tear
Social History:
___
Family History:
Family history of melanoma - daughter
Physical ___:
ADMISSION PHYSICAL EXAM
=========================
GENERAL: Alert and interactive, in no acute distress but mildly
tachypneic, on 6L NC. Productive cough with yellow/brown viscous
sputum.
HEENT: NCAT, PERRL, EOMI. Sclera anicteric and without
injection.
NECK: JVP difficult to assess but may be elevated to the angle
of
the mandible.
CARDIAC: Regular rhythm, mildly tachycardic. S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Tachypneic, intermittent inspiratory and expiratory
wheeze, rhonchorous breath sounds and crackles from mid lung
fields to bases, decreased breath sounds at the bases
bilaterally.
BACK: No CVA tenderness.
ABDOMEN: Soft, non-distended, non-tender to deep palpation in
all
four quadrants. No organomegaly.
EXTREMITIES: 2+ pitting edema of the lower extremities
bilaterally from ankles distally.
SKIN: Warm, no rash. R-sided chest port without erythema, c/d/I.
Punctate area of skin breakdown on R buttock.
NEUROLOGIC: AOx3.
DISCHARGE PHYSICAL EXAM
========================
Temp: 98.4 (Tm 98.4), BP: 97/57 (91-108/47-65), HR: 91 (80-93),
RR: 18 (___), O2 sat: 96% (90-97), O2 delivery: Ra, Wt: 153.6
lb/69.67 kg
Last 24 hours Total cumulative -893ml
IN: Total 480ml, PO Amt 480ml
OUT: Total 1373ml, Urine Amt 1373ml
GENERAL: Sitting in bed, comfortable
HEENT: NCAT, PERRL, EOMI. Sclera anicteric and without
injection.
CARDIAC: Regular rhythm, rate. S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Inspiratory and expiratory scattered wheeze, coarse
rhonchorous breath sounds from mid lung fields to bases,
decreased breath sounds at the bases bilaterally
ABDOMEN: Soft, non-distended, non-tender to deep palpation in
all
four quadrants. No organomegaly.
EXTREMITIES: trace pitting edema bilaterally in dorsum of feet.
SKIN: Warm, no rash. R-sided chest port without erythema, c/d/I.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS
==================
___ 04:30PM WBC-11.5* RBC-3.40* HGB-11.7* HCT-33.8*
MCV-99* MCH-34.4* MCHC-34.6 RDW-13.1 RDWSD-46.7*
___ 04:30PM NEUTS-76.9* LYMPHS-15.9* MONOS-5.5 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-8.86* AbsLymp-1.83 AbsMono-0.63
AbsEos-0.06 AbsBaso-0.02
___ 04:30PM PLT COUNT-168
___ 04:30PM GLUCOSE-88 UREA N-18 CREAT-1.0 SODIUM-129*
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-21* ANION GAP-13
___ 04:47PM LACTATE-1.5
___ 04:30PM proBNP-1200*
___ 04:47PM LACTATE-1.5
___ 06:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:07PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:51PM ___ PO2-57* PCO2-39 PH-7.41 TOTAL CO2-26
BASE XS-0 COMMENTS-GREEN TOP
___ 10:51PM LACTATE-0.9
DISCHARGE LABS
==================
Right-sided Port-A-Cath with its tip in the right atrium.
___ 06:50AM BLOOD WBC-12.8* RBC-2.86* Hgb-9.8* Hct-29.0*
MCV-101* MCH-34.3* MCHC-33.8 RDW-12.8 RDWSD-48.4* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-77 UreaN-39* Creat-0.9 Na-136
K-4.1 Cl-93* HCO3-30 AnGap-13
___ 06:50AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.1
MICRO
===================
___ Blood culture x2 negative
___ Legionella Urinary antigen negative
IMAGING/STUDIES
===================
CXR ___
FINDINGS:
Right sided Port-A-Cath tip terminates in the low SVC. Heart
size is normal.
Atherosclerotic calcifications are noted at the aortic knob.
Prominent
mediastinal and hilar contours are unchanged, likely reflective
of underlying lymphadenopathy. Pulmonary vasculature is not
engorged. Patchy opacities are noted in the lung bases, in the
region of known bronchiectasis. No pleural effusion or
pneumothorax. No acute osseous abnormality.
IMPRESSION:
Patchy opacities in the lung bases in a region of
bronchiectasis, which may reflect pneumonia.
TTE ___
The left atrial volume index is mildly increased. The right
atrium is mildly enlarged. There is normal left
ventricular wall thickness with a normal cavity size. There is
mild global left ventricular hypokinesis.
Quantitative biplane left ventricular ejection fraction is 50 %.
There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus is
mildly dilated with mildly dilated ascending aorta. The aortic
arch diameter is normal. The aortic valve
leaflets (3) are mildly thickened. A filamentous strand(s) is
seen on the aortic valve c/w Lambl's
excresence (normal variant). There is no aortic valve stenosis.
There is a centrally directed jet of mild
[1+] aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse.
No masses or vegetations are seen on the mitral valve. There is
trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild global left ventricular systolic dysfunction.
MIld aortic regurgitation.
CT CHEST ___
IMPRESSION:
Diffuse bilateral ground-glass opacification somewhat patchy,
could represent pulmonary edema. Atypical pneumonia can have a
similar appearance.
Small volume mediastinal and hilar adenopathy is unchanged.
CXR ___
IMPRESSION:
Subtle bilateral parenchymal opacities appear worse compared to
radiograph
from ___ however, have subtly improved compared to
chest CT from ___.
CXR ___
IMPRESSION:
Comparison to ___. Stable right apical
calcifications, 1 of which
is nodular in appearance. Stable parenchymal morphology.
Stable correct
position of the right pectoral Port-A-Cath. Normal size and
shape of the
cardiac silhouette.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/cough
2. Lisinopril 2.5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO QHS
4. Mirtazapine 7.5 mg PO QHS
5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
6. Rivaroxaban 20 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*0
2. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth daily Disp #*60 Tablet Refills:*0
3. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
4. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
5. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
6. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
7. Metoprolol Succinate XL 12.5 mg PO QHS
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*15 Tablet Refills:*0
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/cough
10. Atorvastatin 40 mg PO QPM
11. Mirtazapine 7.5 mg PO QHS
12. Omeprazole 20 mg PO DAILY
13. Rivaroxaban 20 mg PO DAILY
14. HELD- Lisinopril 2.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells you to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute hypoxic respiratory failure
Bronchiectasis exacerbation
Acute on chronic diastolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with SOB// r/o acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT ___ and chest radiograph ___
FINDINGS:
Right sided Port-A-Cath tip terminates in the low SVC. Heart size is normal.
Atherosclerotic calcifications are noted at the aortic knob. Prominent
mediastinal and hilar contours are unchanged, likely reflective of underlying
lymphadenopathy. Pulmonary vasculature is not engorged. Patchy opacities are
noted in the lung bases, in the region of known bronchiectasis. No pleural
effusion or pneumothorax. No acute osseous abnormality.
IMPRESSION:
Patchy opacities in the lung bases in a region of bronchiectasis, which may
reflect pneumonia.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with history of CLL/SLL with pulmonary
parenchymalinvolvement diagnosed in ___ s/p chemotherapy (last in ___ now
with acute hypoxic respiratory failure secondary to bronchiectasis, HFrEF and
likely pneumonia// Progression of bronchiectasis Progression of
bronchiectasis
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions. The technical details of the protocol are consistent with the
___ of Radiology (___) requirements for low-dose CT lung cancer
screening*
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 39.7 cm; CTDIvol = 12.7 mGy (Body) DLP = 502.9
mGy-cm.
Total DLP (Body) = 503 mGy-cm.
COMPARISON: To a prior study done on ___
FINDINGS:
THORACIC INLET: There is a right-sided Port-A-Cath with its tip in the right
atrium there are multiple small bilateral supraclavicular lymph nodes mildly
enlarged, unchanged since the prior study
BREAST AND AXILLA : There are multiple small bilateral axillary lymph nodes
not enlarged by size criteria measuring up to 6 mm, also unchanged.
MEDIASTINUM: The mediastinal lymph nodes are enlarged and unchanged since the
prior study the right paratracheal node measures 9 mm. The right lower
paratracheal node measures 16 mm. The left paratracheal node measures 9 mm.
There are small bilateral hilar lymph nodes. The subcarinal node measures 11
mm. There is moderate cardiomegaly. There are multiple small periesophageal
lymph nodes. There is a small hiatus hernia.
PLEURA: There is no pleural effusion.
LUNG: Evaluation of lung parenchyma is somewhat limited due to respiratory
motion. There is multifocal bilateral parenchymal opacities, somewhat in a
perihilar distribution, most likely represents pulmonary edema. There is
bibasilar atelectasis.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine.
UPPER ABDOMEN: Limited sections through the upper abdomen shows a small hiatus
hernia. There is atherosclerotic calcification involving the aorta. There
are multiple bilateral renal cysts. No adrenal masses are seen in the left
adrenal is diffusely thickened. Small upper abdominal lymph nodes are
unchanged
IMPRESSION:
Diffuse bilateral ground-glass opacification somewhat patchy, could represent
pulmonary edema. Atypical pneumonia can have a similar appearance.
Small volume mediastinal and hilar adenopathy is unchanged.
Right-sided Port-A-Cath with its tip in the right atrium.
Radiology Report
INDICATION: ___ with history of CLL/SLL with pulmonary parenchymal
involvement diagnosed in ___ s/p chemotherapy (last in ___ c/b
hypogammaglobulinemia on monthly IVIG and recurrent PNA, bronchiectasis,
chronic systolic heart failure (LVEF 40-45% in ___, and atrial fibrillation
on rivaroxaban (TIA while on warfarin) who presents with subacute
progressively worsening cough and SOB and new hypoxia.// Question of PNA
progression vs other intrapulmonary process
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recent dated ___.
FINDINGS:
Lungs are fully expanded. Subtle bilateral parenchymal opacities appear worse
compared to radiograph from ___ however, have subtly improved
compared to chest CT from ___. This could represent a resolving
pneumonitis or atypical pneumonia. No pleural effusion or pneumothorax.
Cardiomediastinal silhouette is within normal limits. Calcified tortuous
thoracic aorta. Single-lumen port seen projecting over the right hemithorax
and terminates in the mid-distal SVC.
IMPRESSION:
Subtle bilateral parenchymal opacities appear worse compared to radiograph
from ___ however, have subtly improved compared to chest CT from ___.
RECOMMENDATION(S): Recommend repeat chest radiograph in ___ weeks to ensure
resolution of parenchymal opacities.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with PNA, ?pneumonitis and improving lung exam
after diuresis and steroids// Change in CXR compared to prior, any evidence of
pulmonary edema Change in CXR compared to prior, any evidence of pulmonary
edema
IMPRESSION:
Comparison to ___. Stable right apical calcifications, 1 of which
is nodular in appearance. Stable parenchymal morphology. Stable correct
position of the right pectoral Port-A-Cath. Normal size and shape of the
cardiac silhouette.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea
Diagnosed with Other pneumonia, unspecified organism, Dyspnea, unspecified
temperature: 98.9
heartrate: 96.0
resprate: 18.0
o2sat: 94.0
sbp: 119.0
dbp: 47.0
level of pain: 0
level of acuity: 2.0 | ATIENT SUMMARY
=====================
___ with history of CLL/SLL with pulmonary parenchymal
involvement diagnosed in ___ s/p chemotherapy (last in ___
c/b hypogammaglobulinemia on monthly IVIG and recurrent PNA,
bronchiectasis, chronic systolic heart failure (LVEF 40-45% in
___, and atrial fibrillation on rivaroxaban (TIA while on
warfarin) who presents with subacute progressively worsening
cough and SOB and new hypoxia.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with a history of recent babesiosis
infection, HTN, HLD, and T2DM, who presented initially with
dyspnea on exertion, and is transferred from ___ for
"pre-tamponade."
He was admitted to ___ from ___ with sepsis, renal
failure, and hyperkalemia, where he was noted to have
splenomegaly to 15cm, and Babesia Microti PCR positive. He was
treated with Atovaquone and Azithromycin.
Since then, he has had significant bilateral lower extremity
edema, dyspnea on exertion, and orthopnea. These symptoms
started 2 weeks ago, but have been improving. Otherwise, he
feels well, with no chest pain, nausea, vomiting, or abdominal
pain.
Earlier today, he presented for routine follow-up TTE, was
found to have EF 51%, a small circumferential pericardial
effusion with 30% respiratory variation, diastolic RA collapse,
dilated IVC suggesting high artery filling pressures with
findings suggestive of pre-tamponade physiology. He was
subsequently referred to the ER where he had lab testing showing
a BNP of 73 troponin of 0.03, normal LFTs, mild anemia with a
hemoglobin of 12. Cardiology was consulted there and are
recommended transport here.
- In the ED initial vitals were: 98.0, 75, 188/88, 17, 94% RA
- EKG: NSR, nonspecific ST changes, Low voltage
- Labs/studies notable for:
WBC 6.3 Hb 11.5 Plt 205
Prst smear negative
Cr 1.1
Trop < 0.01
lactate 1.4
Imaging showed:
CXR: Opacities at the posterior costophrenic angles could be
due to small effusions and atelectasis noting that infection is
not excluded. No pulmonary edema.
Patient was given: no medications
Cardiology was consulted, and recommended admission to ___ for
repeat TTE & workup of ___.
ID was called, and recommended Atovaquone and Azithro only if
patient decompensates, pending smear (which ultimately was
negative)
Vitals on transfer: 77 147/80 16 96% RA
On the floor, he reports no current dyspnea, chest
pain/pressure, palpitations, lightheadedness, n/v, fevers,
diaphoresis, myalgias, or any other complaints.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Social History:
___
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.4 ___
Pulsus: 10 mmHg
GENERAL: NAD
HEENT: NCAT. Sclera anicteric. MMM.
NECK: No jugular venous distention.
CARDIAC: RRR, murmurs, rubs, or gallops heard in upright or
supine position
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No tenderness.
EXTREMITIES: 2+ pitting edema bilaterally
Discharge Exam:
PHYSICAL EXAMINATION:
VS: Temp: 98.4 HR 78 BP: 138/72 94% RA
GENERAL: feeling well in NAD laying in bed watching TV
HEENT: Sclera anicteric. mucus membranes are moist, EOMI
NECK: JVP not appreciated on exam
CARDIAC: RRR, no murmurs, rubs, or gallops heard in upright or
supine position
LUNGS: breathing was unlabored, no wheezes, rhonchi or rales,
clear to auscultation in all lung fields
ABDOMEN: Soft, No tenderness.
EXTREMITIES: 2+ pitting edema bilaterally to mid calf, most
notable in the ankles up to his knees bilaterally
SKIN: no rash
MSK: No obvious joint effusion
Pertinent Results:
ADMISSION LABS:
___ 01:30PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 01:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:30PM PARST SMR-NEG
___ 01:30PM URINE UHOLD-HOLD
___ 01:35PM PLT COUNT-205
___ 01:35PM PLT COUNT-205
___ 01:35PM NEUTS-63.4 ___ MONOS-8.8 EOS-4.9
BASOS-1.1* IM ___ AbsNeut-4.01 AbsLymp-1.36 AbsMono-0.56
AbsEos-0.31 AbsBaso-0.07
___ 01:35PM WBC-6.3 RBC-4.03* HGB-11.5* HCT-36.0* MCV-89
MCH-28.5 MCHC-31.9* RDW-14.2 RDWSD-46.0
___ 01:35PM ALBUMIN-3.4* CALCIUM-9.1 PHOSPHATE-3.5
MAGNESIUM-1.6
___ 01:35PM CK-MB-3 cTropnT-0.01
___ 01:35PM ALT(SGPT)-12 AST(SGOT)-14 CK(CPK)-54 ALK
PHOS-81 TOT BILI-0.5
___ 01:35PM estGFR-Using this
___ 01:35PM GLUCOSE-184* UREA N-31* CREAT-1.1 SODIUM-140
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 05:00PM ___ PTT-27.6 ___
___ 05:20PM LACTATE-1.4
Imaging/Studies:
CXR ___
IMPRESSION:
Opacities at the posterior costophrenic angles could be due to
small effusions
and atelectasis noting that infection is not excluded. No
pulmonary edema.
ECHO ___ TTE
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF = 70%). Doppler parameters are
most consistent with Grade II (moderate) left ventricular
diastolic dysfunction. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Trace aortic regurgitation is seen.
Physiologic mitral regurgitation is seen (within normal limits).
The pulmonary artery systolic pressure could not be determined.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Suboptimal image quality. Small pericardial
effusion; no cardiac tamponade.
Head CT:
___
FINDINGS:
There is a chronic appearing lacune in the left putamen. There
is no evidence
of acute large territorial infarction,hemorrhage,edema, or mass.
The
ventricles and sulci are normal in size and configuration for
age. There are
minimal calcifications in the right carotid siphon.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality. Tiny chronic left putamen
lacune.
Microbiology
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ (LYME)Lyme IgG-FINAL; Lyme IgM-FINAL
NegativeINPATIENT
___ CULTUREBlood Culture,
Routine-PRELIMINARY {STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle
Gram Stain-FINALEMERGENCY WARD
___ (LYME)Lyme IgG-FINAL; Lyme
IgM-FINALEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PRELIMINARY {STAPHYLOCOCCUS EPIDERMIDIS}; Anaerobic
Bottle Gram Stain-FINALEMERGENCY WARD
___ CULTURE-FINALEMERGENCY WARD
Discharge Labs:
___ 05:55AM BLOOD WBC-6.3 RBC-4.35* Hgb-12.5* Hct-40.3
MCV-93 MCH-28.7 MCHC-31.0* RDW-14.3 RDWSD-48.2* Plt ___
___ 05:55AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.1
___ 06:30AM BLOOD TSH-2.8
___ 01:30PM URINE Hours-RANDOM Creat-29 Albumin-129.0
Alb/Cre-4448.3*
___ 01:30PM URINE Blood-NEG Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Furosemide Dose is Unknown PO DAILY
4. Glargine 65 Units Bedtime
5. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth Once daily in the
morning Disp #*30 Tablet Refills:*0
3. Glargine 65 Units Bedtime
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
acute on chronic diastolic heart failure
hypertension
diabetes, insulin dependent
GPC bacteremia
SECONDARY DIAGNOSES:
history of babesiosis
history of acute kidney injury, now resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with SOB// ?pulm edmea
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Opacity projects over the posterior costophrenic angles on the lateral view.
Superiorly, lungs are clear. Cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities, degenerative changes seen at the
right shoulder and hypertrophic changes noted in the spine.
IMPRESSION:
Opacities at the posterior costophrenic angles could be due to small effusions
and atelectasis noting that infection is not excluded. No pulmonary edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with a history of recent babesiosis infection, HTN, HLD, and
T2DM, who presented with SOB and fluid overloaded, found to have GPC
bacteremia now with worsening severe headache.// ?Abscess/acute intracranial
pathology
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 844 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a chronic appearing lacune in the left putamen. There is no evidence
of acute large territorial infarction,hemorrhage,edema, or mass. The
ventricles and sulci are normal in size and configuration for age. There are
minimal calcifications in the right carotid siphon.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality. Tiny chronic left putamen lacune.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Leg swelling, XFER
Diagnosed with Disease of pericardium, unspecified
temperature: 98.0
heartrate: 75.0
resprate: 17.0
o2sat: 94.0
sbp: 188.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | Key Information for Outpatient ___ with a history of
recent babesiosis infection, HFpEF, HTN, HLD, and T2DM, who
presented initially with dyspnea on exertion, and is transferred
from ___ for "pre-tamponade," with repeat TTE showing no
significant effusion and no tamponade, but clinically he is
significantly volume overloaded. Later in the course of his
hospital stay he was found to have 2 out of 4 blood cultures
that were positive for gram-positive cocci in pairs that
ultimately speciated to staph epidermidis. ID was consulted and
they felt that as long as he had no growth off of vancomycin for
48 hours, the suspicion for a true infection was low. Blood
cultures 48 hours after antibiotic discontinuation remain
negative.
#HFpEF exacerbation: Presented with history of orthopnea and ___
edema that started at end of his recent hospitalization. This
was most likely multifactorial: diastolic dysfunction in setting
of HTN, volume resuscuitation and renal failure as well as
hypoalbuminemia at last hospitalization. TTE was notable for
normal systolic function with Grade II (moderate) left
ventricular diastolic dysfunction. His BP was significantly
elevated on admission here which may have been exacerbating his
diastolic heart failure. Renal failure resolved by this
admission. He was diuresed with boluses of 20 IV Lasix with
improvement and transitioned to po Lasix 20 mg on discharge due
to continued bilateral lower extremity edema. For his
hypertensive heart disease, amlodipine was added to his
Lisinopril regimen
#GPCs on blood cultures x2, suspected contaminant: ___ blood
cultures returned positive for staph epidermidis, but patient
clinically well (no fever or leukocytosis). He was started on
Vancomycin, but this was stopped after 48 hours per ID
recommendations, and daily cultures monitored for clearance
(several remain pending on day of discharge). His TTE was
re-evaluated by cardiology and they did not see any
vegetations. He was discharged with a plan to see PCP the day
after discharge to follow-up on these blood cultures and obtain
new cultures; if cultures from ___ days after stopping ABx
remain negative, then this is most likely a contaminant.
#Albuminuria: Patient had a alb/cr. ratio in the 4000s range.
This is severe proteinuria. He has a history of diabetes on
insulin at home so this could be secondary to diabetic
nephropathy. We think this was most likely secondary to his
underlying diabetic nephropathy and he will see nephrology on
discharge for further follow-up
___: Patient developed mild pre-renal ___ after aggressive
diuresis. Creatinine returned to baseline of 1.2 on discharge
after holding IV diuresis
#History of elevated ___: At OSH had elevated ___ 1:1280,
speckled pattern. Rheumatology was consulted and recommended to
repeat the ___. His overall picture did not fit for a distinct
rheumatologic disease and they did not recommend further
follow-up |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute right-sided weakness, ataxia and dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo RH male with HTN/HLD p/w with acute onset
right-sided weakness, clumsiness and dysarthria. The patient
went to work ___ around 7 AM and was reportedly feeling well.
Works as a ___ and worked through the AM. Around 11 AM the
patient appeared diaphoretic, seen by coworkers tripping over
objects at work. His boss encouraged him to relax and cool off
in the AC. About an hour or so later, he apeared well, speaking
normally and walking fine.. Around 2:30 ___ the patient's boss
again noticed him appearing very clumsy. He told him to go to
the ED. He called his brother to come pick him up and his
brother reports that he was dysarthric and falling to the right.
After subsequent interviews and clarification the patient
reported,
that he did not feel well at 11 and never returned to baseline.
He reported having dyasrthria around 1 ___ and having a clumsy
hand while working on the cars in the afternoon. He then later
felt as though his right leg was clumsy as well - around 2:30.
In the ED, the patient reports chest pain and tingling in his
bilateral fingertips. The chest pain he gets on almost a daily
basis without clear pattern. Can occur at rest, with exertion or
when lying down. On arrival the patient's pressure was 208/110
and was given labetalol and then placed on a nicardipine drip. A
foley was placed per tPA protocol. EKG demonstrate ST elevations
in V1-V3 and T wave inversions in V4-6. The findings were
discussed with Cardiology who felt this was consistent to LVH
related to HTN.
Review of Systems: No HA, loss of vision, lightheadedness,
vertigo, diplopia, dizziness, dysarthria, dysphagia, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae, except as above. No bowel or bladder incontinence.
Gait problems.
Past Medical History:
HTN
Hyperlipidemia
Social History:
___
Family History:
Strong family hx of HTN. No strokes
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.4 P: 98, R: 16 BP: 218/104 SaO2: 100 % RA
Neurologic:
-Mental Status: Alert, oriented x name, place and month, and
year. Relates history, albeit needs clarification over three
exams. Speech is dysarthric. Language is fluent. Normal
prosody.
Reading intact. There were no paraphasic errors. Pt. was able
to
name high, but not low frequency objects. Able to follow one
and
two step commands crossing the midline. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation, although
intially had some trouble counting fingers that was likely
attentional.
III, IV, VI: EOMI with nystagmus on left lateral gaze. Normal
saccades.
V: Facial sensation intact to light touch.
VII: No facial asymmetry. Normal facial movements.
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. Pronator drift on the right. No
adventitious movements, such as tremor, noted. No asterixis
noted. Impaired finger tapping and coordinated movements in the
right hand.
Delt Bic Tri WrE WrF FFl FE IP Quad Ham TA ___
L 5 ___ ___- ___ 5 5 5
R 5 ___ ___- ___ 5 5 5
-Sensory: No deficits to light touch, pinprick b/l. Extinction
to DSS on the RUE.
-DTRs:
Bi ___ Pat Ach
L 2 2 2 2
R 2 2 2 2
Plantar response was flexor bilateraly. No clonus.
- Coordination: Dysmetria on FNF and heel to shin on the right.
-Gait: Not assessed.
Pertinent Results:
___ 07:55PM GLUCOSE-124* UREA N-16 CREAT-1.2 SODIUM-138
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
___ 07:55PM cTropnT-<0.01
___ 07:55PM URINE HOURS-RANDOM SODIUM-98 POTASSIUM-11
CHLORIDE-81
___ 07:55PM URINE OSMOLAL-369
___ 07:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:56PM GLUCOSE-99 NA+-141 K+-3.8 CL--101 TCO2-26
___ 03:45PM CREAT-1.5*
___ 03:45PM UREA N-18
___ 03:45PM estGFR-Using this
___ 03:45PM cTropnT-<0.01
___ 03:45PM OSMOLAL-289
___ 03:45PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 03:45PM WBC-6.5 RBC-5.29 HGB-17.0 HCT-48.9 MCV-93
MCH-32.2* MCHC-34.7 RDW-12.6
___ 03:45PM PLT COUNT-290
___ 03:45PM ___ PTT-36.1 ___
Head CT: No intracranial hemorrhage, edema, mass, or mass
effect.
CTA: Carotid arteries and vertebral arteries in the neck are
widely patent without dissection, hematoma, filling defects. The
circle of ___ and its principal branches are patent. There is
no large aneurysm, vascular malformation, occlusion, or high
grade stenosis. CTP: No vascular territorial perfusion
abnormalities are seen.
MRI ___: Slow diffusion is identified in the posterior limb of
the left
internal capsule, demonstrated on the DWI and ADC maps, this
area measures
approximately 5 x 21 mm in transverse dimension, there is no
evidence of
susceptibility changes to suggest hemorrhagic transformation, no
significant mass effect is identified, there is no evidence of
hydrocephalus. The FLAIR sequence and T2-weighted images
demonstrate a focal area of high signal intensity in the
subcortical white matter of the left frontal lobe, possible.
IMPRESSION: Slow diffusion is identified in the posterior limb
of the left internal capsule, likely consistent with an acute
ischemic event. There is no evidence of hemorrhagic
transformation or mass effect.
2D ECHO: Marked symmetric left ventricular hypertrophy with
normal regional and low normal global systolic function.
Mild-moderate mitral regurgitation. Incresaed PCWP. No PFO/ASD
identified. No definite cardiac source of embolism identified.
EKG ___: Sinus rhythm. Left atrial abnormality. Left axis
deviation. Left ventricular hypertrophy with secondary
repolarization change. Compared to the previous tracing of
___ no diagnostic interim change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 142 80 434/449 60 -23 174
Medications on Admission:
Nil
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Fluoxetine 20 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Cerebral embolism with infarction
Hypertension, Hyperlipidemia, Tobacco abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
STUDY: CTA of the head and neck.
CLINICAL INDICATION: ___ male patient with history of ataxia,
evaluate posterior fossa for intracranial hemorrhage or ischemia.
COMPARISON: No prior examinations are available.
TECHNIQUE: Axial non-contrast images were obtained through the brain.
Subsequently, axial MDCT images were obtained from the aortic arch through the
head convexity with intravenous contrast material, axial, coronal, and
sagittal thick-slab multiplanar reformations were generated. Curved
reformations and 3D volume-rendered reconstructions of the intracranial and
cervical circulations were also generated at the separate workstation by the
advanced imaging lab.
CT PERFUSION: Also perfusion sequence was obtained, and color maps for
detection of the mean transit time, blood flow, and blood volume were
obtained.
FINDINGS:
NON-CONTRAST HEAD CT: There is no evidence of intracranial hemorrhage, mass,
mass effect, or shifting of the normally midline structures. The ventricles
and sulci are normal. The orbits are unremarkable, the paranasal sinuses and
mastoid air cells are clear.
CTA OF THE HEAD: There is vascular anatomical variation consistent with
hypoplasia of the A1 segment on the right. The right posterior communicating
artery is patent with fetal pattern. The anterior communicating artery
demonstrates three anterior cerebral arteries. There is atherosclerotic
plaque at the bifurcation of the left middle cerebral artery, with tortuosity
of the inferior branch, no aneurysms larger than 3 mm in size are seen. There
is no evidence of vascular malformation or high-grade stenosis.
CTA OF THE NECK: The aortic arch demonstrates a three-vessel branch
morphology, the common carotid arteries are widely patent as well as the
vertebral arteries with no evidence of flow stenotic lesion.
CTA PERFUSION: There is no evidence of abnormal mean transit time, blood flow,
or cerebral blood volume to indicate areas of ischemia or penumbra. If there
is persistent or significant clinical concern for acute infarction,
correlation with MRI of the brain is advised.
Radiology Report
HISTORY: ___ man with CVA and worsening mental status.
COMPARISON: ___ nonenhanced head CT and head CTA.
TECHNIQUE: Contiguous axial MDCT sections were obtained through the brain
without administration of IV contrast. Coronal and sagittal reformations, and
thin slice bone algorithm reconstructions were reviewed.
FINDINGS:
Hypodensity in the anterior limb of the left internal capsule (2:18) is
slightly more conspicuous than on the exam 4 hours prior, but this could be
accounted for by differences in patient positioning, volume averaging, and
slice selection. There is no evidence of hemorrhage, mass effect, or large
territorial infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation. The pineal gland is slightly prominent
measuring approximately 15 mm in anterio-posterior by 14 mm in transverse
dimension and partially calcified.
No fracture is identified. A mucous retention cyst is present in the right
maxillary sinus. The visualized paranasal sinuses, mastoid air cells, and
middle ear cavities are otherwise clear.
IMPRESSION:
No definite change since the study 4 hours prior. Apparent increase in
conspicuity of a focal hypodensity in the anterior limb of the left internal
capsule could be accounted for by differences in technique.
Radiology Report
STUDY: MRI of the head.
CLINICAL INDICATION: ___ man with ataxia, hemiparesis, stroke.
COMPARISON: Prior CTA of the head dated ___.
TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility,
and axial diffusion-weighted sequences were obtained through the brain.
FINDINGS: Slow diffusion is identified in the posterior limb of the left
internal capsule, demonstrated on the DWI and ADC maps, this area measures
approximately 5 x 21 mm in transverse dimension, there is no evidence of
susceptibility changes to suggest hemorrhagic transformation, no significant
mass effect is identified, there is no evidence of hydrocephalus. The FLAIR
sequence and T2-weighted images demonstrate a focal area of high signal
intensity in the subcortical white matter of the left frontal lobe, possibly
consistent with lacunar ischemic change. The major vascular flow voids are
present, the orbits are unremarkable, the paranasal sinuses demonstrate a
mucus-retention cyst on the right maxillary sinus, the mastoid air cells are
clear.
IMPRESSION: Slow diffusion is identified in the posterior limb of the left
internal capsule, likely consistent with an acute ischemic event. There is no
evidence of hemorrhagic transformation or mass effect.
These findings were discovered and communicated via phone call to Dr. ___
___ at 17:30 hours on ___ by Dr. ___.
Radiology Report
HISTORY: Right ataxia hemiparesis syndrome, status post t-PA. Evaluate for
hemorrhage.
TECHNIQUE: Contiguous axial images were obtained of the brain. No contrast
was administered.
COMPARISON: CT head on ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass, mass effect, or CT
evidence of acute territorial infarction. The ventricles sulci are normal in
size and configuration for the patient's age. The previously seen hypodensity
in the anterior limb of the internal capsule is not well seen. Visualized
paranasal sinuses and mastoid air are well aerated.
IMPRESSION:
No evidence of acute hemorrhage.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Weakness
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: 98.4
heartrate: 98.0
resprate: 16.0
o2sat: 97.0
sbp: 218.0
dbp: 104.0
level of pain: nan
level of acuity: 1.0 | Mr. ___ was admitted to the neuroICU after receiving ___
dose tPA (by weight). This was terminated abruptly, after it was
learnt that the original onset of his symptoms was well before
the first related time of 2PM. He remained hemodynamically
stable in the ICU and follow up neuroimaging did not show any
hemorrhage in his brain. His examination was significant for
profound weakness of the right arm, with gradually improving
weakness of the right leg.
- He was followed closely by physical therapy throughout his
stay who judged him to be a good candidate for acute
rehabilitation. At the time of discharge, his physical
examination was notable for right arm plegia, slight pyramidal
weakness of the right leg, and right facial weakness.
- His cholesterol returned elevated and so he was started on a
statin. He was also continued on an aspirin, and his BP control
required three agents.
- He was counseled by our nutritionist about the importance of
healthy food choices.
- His EKG showed profound elevations of the ST-segment
consistent with a J-point elevation. He never had chest pain or
chest discomfort. Echo showed LVH, and so he will follow up with
cardiology in 6 weeks.
- He was quite tearful at the initial presentation, and his
motivation and participation was rather poor at times. He was
agreeable to starting on a low dose of fluoxetine, with the
goals that improving his mood may assist with his overall
recovery. His family visited him on numerous occasions during
his stay.
TRANSITIONAL ISSUES:
- We apologize that we were unable to set up his follow up
appointments prior to discharge, but they will be set up. We
will contact his rehabilitation facility directly to ensure that
those are communicated.
- HCTZ may need to be uptitrated as needed to control his BPs
- Would continue to encourage smoking cessation. While on the
floor, he did not require nicotine supplementation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ - cerebral angiogram
History of Present Illness:
Mr. ___ is a ___ year-old male with history of hepatitis C,
sleep apnea, peptic ulcer disease, presenting to the ___ ED
directly from radiology with an acute right-sided SDH. He
reports
approximately 1 week of worsening headache. He denies any trauma
or minor headstrike. He had an episode of nausea & vomiting 3
days ago, with mild nausea since. His family reports decreased
appetitite and general malaise. He was seen in urgent care
yesterday and had a scheduled MRI this afternoon which revealed
an acute right convexity SDH. He was referred directly to the ED
for Neurosurgical evaluation. He is prescribed Aspirin 81mg
daily
for "general health". He reports taking more Aspirin than
prescribed this week (162mg-325mg daily) for headaches. No
history of stroke or aneurysm. Today, he does admit to mild
headache. Denies visual changes, new numbness or weakness in
arms
or legs. He does report slight difficulty using his right hand.
No difficulties with speech.
Past Medical History:
Colorectal polyps
Sleep apnea, severe
BPH (benign prostatic hyperplasia)
PEPTIC ULCER DISEASE
Social History:
___
Family History:
father - well in his ___ [OTHER]
Mother liver ca [OTHER]
Physical Exam:
On admission
O: T: 97.0 BP: 150/95 HR: 67 RR: 18 O2Sats: 99%
Gen: WD/WN, mildly uncomfortable with eyes closed.
HEENT: No external signs of trauma.
Neck: Supple. Full ROM without pain.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not assessed
II: Pupils equally round and reactive to light, 3 to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength slightly diminished on left UE & ___, 4+/5
throughout. No pronator drift.
Sensation: Intact to light touch.
Coordination: No dysmetria with finger-nose-finger. Slowed fine
motor movements on left.
On discharge
Neurologically intact, groin CDI with no edema, non tender
Pertinent Results:
___ NCHCT
Moderate acute right hemispheric subdural hematoma measuring
approximately 1.2
cm in maximal thickness, with mild leftward shift of midline
structures.
Close interval followup is recommended.
___ CTA head
Unchanged right hemispheric subdural hematoma resulting in 4 mm
leftward midline shift. No acute infarct or new hemorrhage.
Essentially unremarkable CTA of the head. No evidence of
vascular malformation or active contrast extravasation.
___
No significant interval change to the right hemispheric subdural
hematoma
measuring up to 1.5 cm from the inner table.
2. Grossly stable mass effect with associated 6 mm leftward
midline shift.
3. Ventricles are stable in size.
___ CXR
Lungs are fully expanded and clear. Mediastinum in the region
of the
ascending thoracic aorta is slightly bulged to the right likely
due to dilated
or tortuous ascending thoracic aorta. Heart is normal size,
pulmonary
vasculature is not dilated and there is no pleural abnormality.
___ cerebral angiogram
No abnormal arterial malformations identified cause of the
patient's a
Preliminary Reporttraumatic subdural hemorrhage.
___ NCHCT
Stable right hemispheric subdural hematoma, measuring up to 15
mm, with
layering along the right tentorium, as described.
2. Grossly stable 5 mm leftward midline shift.
3. No new hemorrhage is identified.
Medications on Admission:
Asa 81 daily and 162-325 PRN headache, omeprazole, amlodipine
Discharge Medications:
1. Amlodipine 2.5 mg PO BID
2. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 8 hours as needed
Disp #*15 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Daily as needed
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with acute subdural hematoma. Evaluate for
progression
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1003 mGy-cm
CTDI: 55 mGy
COMPARISON: None.
FINDINGS:
No comparisons are available.
There is a hyperdense extra-axial hematoma along the right cerebral
hemisphere, from the vertex to the inferior temporal lobe.
Maximal thickness of the subdural hematoma is 1.2 cm and there is effacement
of the adjacent sulci along the right cerebral hemisphere.
There is resultant mass effect of the cerebral hemisphere with mild midline
shift to the left by 6 mm, as well as mass effect upon the right lateral
ventricle. The basal cisterns are patent.
No overlying fracture or soft tissue swelling is seen. There is minimal
mucosal thickening of the maxillary sinuses bilaterally, otherwise the
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Incidentally noted are osteomas of the left mastoid air cells.
IMPRESSION:
Moderate acute right hemispheric subdural hematoma measuring approximately 1.2
cm in maximal thickness, with mild leftward shift of midline structures.
Close interval followup is recommended.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS
INDICATION: ___ man with nontraumatic subdural hematoma. Evaluate
for underlying vascular lesion and stability of hemorrhage.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed through the
brain during infusion of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated. This report is based on interpretation of all
of these images.
DOSE: DLP: 1859.06 mGy-cm; CTDI: 205.39 mGy
COMPARISON: CT head without contrast of ___.
FINDINGS:
Head CT: Essentially unchanged size of right hemispheric subdural hematoma
also layering along the right tentorial leaflet measuring up to 1.3 cm in
greatest thickness. There is right hemispheric sulcal effacement as well as 4
mm leftward midline shift, unchanged from prior exam. There is unchanged
minimal effacement of the right ambient cistern. No new hemorrhages. There is
no evidence of acute infarct.
Minimal mucosal thickening of the right maxillary sinus. Otherwise the
paranasal sinuses are clear. The orbits are unremarkable. The mastoid air
cells and middle ear cavities are well pneumatized and clear.
Head CTA: There are prominent right hemispheric superficial draining veins,
without evidence of arterial venous malformation. The prominence is likely
secondary to congestion and crowding from local mass effect from the hematoma.
There are no intracranial vascular abnormalities. There is no evidence of
aneurysm, stenosis or occlusion.
IMPRESSION:
1. Stable right hemispheric subdural hematoma resulting in 4 mm leftward
midline shift.
2. No new hemorrhage.
3. Essentially unremarkable CTA of the head.
4. No evidence of vascular malformation or active contrast extravasation
identified.
5. Paranasal sinus disease as described.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with history of right-sided subdural hemorrhage,
now with worsening headache. Evaluate for progression of bleed.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 897 mGy-cm
CTDI: 54 mGy
COMPARISON: ___ head CTA, ___ Head CT.
FINDINGS:
There is redemonstration of a right hemispheric subdural hematoma measuring up
to 1.5 cm from the inner table at the vertex, not significantly changed since
prior study. There is also blood layering along the right tentorium cerebelli.
There is mass effect on the right lateral ventricle, unchanged effacement of
the right cerebral sulci as well as a 6 mm leftward shift of midline
structures. The ventricles are unchanged in size and configuration. There is
no evidence of downward herniation. The basal cisterns appear patent and there
is preservation of gray-white matter differentiation.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No significant interval change to the right hemispheric subdural hematoma
measuring up to 1.5 cm from the inner table.
2. Grossly stable mass effect with associated 6 mm leftward midline shift.
3. Ventricles are stable in size.
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: ___ year old man preop cxr // preop preop
COMPARISON: There are no prior chest radiographs.
IMPRESSION:
Lungs are fully expanded and clear. Mediastinum in the region of the
ascending thoracic aorta is slightly bulged to the right likely due to dilated
or tortuous ascending thoracic aorta. Heart is normal size, pulmonary
vasculature is not dilated and there is no pleural abnormality.
Radiology Report
CLINICAL HISTORY ___ year old man with ___ r/o vascular malformation //
diagnostic cerebral angiogram in morning on ___
EXAMINATION: Patient presented for diagnostic catheter angiography.
The following vessels were selectively catheterize injected: Right common
carotid artery, right internal carotid artery including Three dimensional
rotational angiography and postprocessing on separate work station with
concurrent physician supervision with images being used for final
interpretation, right external carotid artery, right vertebral artery, left
common carotid artery including Three dimensional rotational angiography and
postprocessing on separate work station with concurrent physician supervision
with images being used for final interpretation, left vertebral artery,.
ANESTHESIA: ANESTHESIA: Moderate sedation was provided by administrating
divided doses of 75 mcg of fentanyl and 1.5 mg of midazolam throughout the
total intra-service time of 65 during which the patient's hemodynamic
parameters were continuously monitored by an independent trained radiology
nurse. 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site
TECHNIQUE: OPERATORS: ___, and Dr. ___ physician
performed the procedure. Dr. ___ supervised the trainee during
the key components of the procedure and has reviewed and agrees with the
trainee's findings.
PROCEDURE: Patient was brought to the fluoroscopy suite, ID confirmed via
wrist band. The patient is placed supine on the fluoroscopy table in the
bilateral groins were prepped and draped in usual sterile manner. Time-out
procedure was performed per institutional guidelines. Next the location the
right mid femoral head was located using anatomic and radiographic landmarks.
10 cc of lidocaine was infused in the subcutaneous tissue. A micropuncture kit
was used to gain access to the right femoral artery, serial dilation was
undertaken until a short 5 ___ groin sheath connected to a continuous
heparinized saline flush was inserted. A ___ catheter was advanced
over the 0.038 glidewire in used to select the innominate followed by the
right common carotid artery. Cervical biplane road map imaging was undertaken.
Next, under road mapping technique, the right internal carotid artery was
selected. Intracranial biplane magnified biplane oblique views along with 3
dimensional rotational angiography and processing a separate 3D workstation
was undertaken from this vessel. The catheter was then pulled back into the
right common carotid artery, new road map was undertaken, and the right
external carotid artery was then selected. Extracranial biplane imaging was
then undertaken. Next the catheter was pulled back into the aorta in used to
select the right innominate artery followed by the right vertebral artery.
___ lateral views were then undertaken. The catheter was then pulled back
and the aorta used to select the left common carotid artery. Intracranial
biplane along with cervical biplane imaging was undertaken from this vessel. 3
dimensional rotational angiography with separate processing on a separate 3D
workstation was also undertaken from this vessel. Catheter was then pulled
back into the aorta used to select the left subclavian artery, followed by the
left vertebral artery. Left vertebral artery injection was undertaken in the
intracranial biplane. The catheter was then pulled back into the aorta and
then fully removed from the body. No compression pressure was held over the
right femoral artery for approximately 25 min until hemostasis was achieved.
At the conclusion the procedure, the patient was is neurologic baseline.
FINDINGS:
Right common carotid artery: Cervical bifurcation is well visualized, there is
mild tortuosity at the origin of the right common carotid artery off of the
innominate artery. There is no significant carotid stenosis or carotid
atheromatous disease.
Right internal carotid artery: The distal right ICA, proximal distal MCA and
ACA branches are well-visualized. Vessel caliber smooth and tapering, there is
no evidence of abnormal early venous drainage, or arteriovenous shunting.
There is no evidence of vasculitis or aneurysm formation. Patient is a very
prominent ophthalmic artery, however there is no evidence of abnormal
anastomoses with the venous circulation, or early draining vein identified.
There is however it is normal anastomoses with the external carotid artery
circulation. There is no evidence of a dilated superior ophthalmic vein, the
timing of normal venous drainage is seen, the cavernous sinus is also seen to
be filling.
Right external carotid artery: The internal maxillary artery, occipital
artery, middle meningeal artery, superior temporal artery are well-visualized.
Vessel caliber smooth and tapering. There is no evidence of vasculitis, or
abnormal arteriovenous shunting, or abnormal extracranial to intracranial
anastomoses. There is no identification of a pathologic early draining vein.
Right vertebral artery: The right vertebral artery, right ___, basilar
artery, reflux down the left vertebral artery to the ___, basilar artery,
bilateral AICA, the, SCA, PCAs are also visualized. Vessel caliber smooth and
tapering, there is no identification of aneurysms, or abnormal early venous
drainage. There is no identification of abnormal arteriovenous shunting. In
the high cervical views, posterior muscular branches along with the posterior
meningeal artery are identified off of the right vertebral artery however
there is no abnormal fistulous connection to a sinus, or cortical vein.
Left common carotid artery: The distal left ICA, proximal distal MCA and ACA
branches are well-visualized. This caliber smooth and tapering. There is no
evidence of abnormal early venous drainage, or abnormal arteriovenous
shunting. No aneurysms are identified. Of the ECA vessels visualized, the STA,
middle meningeal, I max are seen. There is no evidence of abnormal
arteriovenous shunting or abnormal extracranial to intracranial anastomoses.
Left vertebral artery: Origin of the left vertebral artery throughout the
cervical plane is visualized. There is no evidence of dissection or abnormal
anastomoses. The left vertebral artery, left ___, basilar artery,
bilateral at AICA and PCA and SCA is are well-visualized. vessel caliber
smooth and tapering. There is no evidence of aneurysm formation, early venous
drainage, or abnormal arteriovenous shunting.
IMPRESSION:
1. No abnormal arterial malformations identified cause of the patient's a
traumatic subdural hemorrhage.
Dr. ___ was personally present, an performed the procedure.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old male with age indeterminate right cerebral hemisphere
subdural hemorrhage, no definite history of prior trauma and negative cerebral
angiogram study. Evaluate stability of subdural hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 935 mGy-cm
CTDI: 54 mGy
COMPARISON: ___ and ___ head CT studies.
FINDINGS:
Again seen, is a right hemispheric primarily hyperdense subdural hematoma
measuring up to 15 mm in greatest width (series 3, image 19). There is also
subdural blood and layering along the right tentorium. There is local mass
effect and continued mild effacement of the right lateral ventricle. There is
approximately 5 mm of leftward shift of midline structures, not significantly
changed. The basal cisterns remain patent and there is preservation of
gray-white matter differentiation. No new areas of hemorrhage are identified.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Stable right hemispheric subdural hematoma, measuring up to 15 mm, with
layering along the right tentorium, as described.
2. Grossly stable 5 mm leftward midline shift.
3. No new hemorrhage is identified.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with HEADACHE
temperature: 97.0
heartrate: 67.0
resprate: 18.0
o2sat: 99.0
sbp: 150.0
dbp: 95.0
level of pain: 9
level of acuity: 2.0 | On ___, the patient was admitted to from the ED for a SDH.
He was neurologically intact and his blood pressure was
agressively controlled in the ICU. He was given a unit of
platelets for aspirin use.
On ___, the patient was neurologically stable. He was
transferred to the step down unit. CTA imaging did not show any
abnormalities.
On ___, the patient underwent diagnostic cerebral
angiography which did not show any evidence of vascular
lesions/abnormalities. He remained stable neurologically.
ON ___, the patient was stable neurologically. Repeat CT
imaging was stble. He ambulated in the halls without any
difficulty, tolerated a PO diet and was able to void. He was
discharged to home in stable condition with follow up
instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ankle pain
Major Surgical or Invasive Procedure:
external fixator device
History of Present Illness:
HPI: Pt is a ___ who presents as a transfer from ___ w/
a R trimalleolar ankle fracture. Pt was painting on a ladder
when
he unfortunately had a fall, landing on his R ankle. He had
immediate pain, deformity, and inability to bear weight. He
presented to ___, was found to have a R trimalleolar ankle
fracture and was transferred to ___ for further management. He
reports no pain elsewhere.
Past Medical History:
___
Social History:
___
Family History:
nc
Physical Exam:
General: Comfortable
MSK: RLE: ex fix intact. Pin sites are c/d/I. Intact gastroc,
TA, ___, EDL/FDL. SILT distally. warm and well perfused.
Soft compartments.
Pertinent Results:
___ 06:47PM GLUCOSE-121* UREA N-15 CREAT-1.0 SODIUM-141
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-23 ANION GAP-20
Medications on Admission:
see admit med list
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 500 mg 2 capsule(s) by mouth every 8 hours for
pain Disp #*100 Capsule Refills:*1
2. Aspirin 325 mg PO DAILY VTE prophylaxis
RX *aspirin 500 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
This is a new medication to prevent constipation. please hold
for loose stools.
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice per day
Disp #*80 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
wean this medication as pain improves
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed for severe pain Disp #*80 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
This is a new medication to prevent constipation. please hold
for loose stools.
RX *sennosides [senna] 8.6 mg 2 tabs by mouth at bedtime Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ankle fracture
Discharge Condition:
AVSS
NAD, A&Ox3
Followup Instructions:
___
Radiology Report
EXAMINATION: CT of the right ankle without contrast
INDICATION: ___ year old man with R pilon fracture// better characterize
fracture pattern around ankle.
TECHNIQUE: Multiplanar CT images of the right ankle without intravenous
contrast.
DOSE: Total DLP (Body) = 302 mGy-cm.
COMPARISON: Right ankle radiographs ___.
FINDINGS:
There is a pilon type fracture at the ankle with transverse/oblique fractures
of the distal fibula and the medial malleolus. There is also a vertically
oriented fracture of the anterior distal tibia with intra-articular extension
and disruption of the articular surface measuring approximately 1.5 cm and
transverse dimension (series 602:61). There are bony fragments within this
area of distraction.
The medial and lateral aspect of the ankle mortise appears congruent without
definite evidence of widening.
No evidence of tendon entrapment.
IMPRESSION:
1. Pilon fracture of the right ankle with a vertically oriented tibial
fracture extending to the articular surface of the tibial plafond.
Transverse/oblique fractures of the distal fibula and medial malleolus also
noted.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: RT ANKLE FX. ORIF
TECHNIQUE: Intraoperative fluoroscopic radiographs of the ankle obtained
without a radiologist present.
Total fluoroscopy time: 13.5 seconds.
COMPARISON: ___. Radiographs of the right ankle ___.
FINDINGS:
Intraoperative radiographs demonstrate placement of external fixation with
screws in the tibial shaft and calcaneus. There are comminuted fractures of
the distal fibula and tibia better assessed on previous dedicated CT. Overall
alignment is unchanged on these limited projections.
IMPRESSION:
Intraoperative radiographs. For further details please refer to the operative
report in the ___ medical record.
Radiology Report
INDICATION: ___ year old man with right ankle fracture// evaluate fracture
extension into tibia
TECHNIQUE: Right knee, two views and right tibia and fibula, two views
COMPARISON: Right ankle radiographs from outside institution ___ at
12:12
FINDINGS:
An overlying splint limits fine osseous detail. Re-demonstrated is a
comminuted intra-articular fracture involving the distal tibia and medial
malleolus, with alignment appearing nearly anatomic. Comminuted distal
fibular fracture with mild lateral and ventral displacement of the dominant
distal fracture fragment appears unchanged. No additional fracture is seen.
No dislocation is identified. The ankle mortise appears symmetric. There are
no concerning lytic or sclerotic osseous abnormalities. The imaged right knee
demonstrates mild degenerative spurring. No gross knee joint effusion is
seen, though assessment is somewhat limited. No radiopaque foreign bodies are
identified. Moderate-sized plantar calcaneal spur is again seen.
IMPRESSION:
Re-demonstration of comminuted distal tibial and fibular fractures without
significant change in alignment. No dislocation.
Radiology Report
INDICATION: ___ year old man with ankle fracture status post splint placement
TECHNIQUE: Right ankle, three views
COMPARISON: Right tibia and fibula ___ at 17:59, right ankle
radiographs ___ at 12:12
FINDINGS:
Overlying splint limits fine osseous detail. Comminuted distal fibular
fracture demonstrates improved alignment with mild ventral and lateral
displacement of the dominant distal fracture fragment. Intra-articular
comminuted distal tibial fracture with involvement of the medial malleolus
also demonstrates improved alignment significant displacement. Ankle mortise
appears symmetric. Talar dome is is smooth. No dislocation or additional
fracture is seen.
IMPRESSION:
Slight interval improvement in alignment of the comminuted distal fibular
fracture. No significant interval change in appearance of nondisplaced
comminuted intra-articular distal tibial fracture with involvement of the
medial malleolus.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with ankle fracture, post op// eval for
cardiopulmonary abnormality
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lung volumes are low with patchy opacities
in the lung bases likely reflective of areas of atelectasis. No focal
consolidation is identified. No pleural effusion or pneumothorax is seen.
There are no acute osseous abnormalities.
IMPRESSION:
Low lung volumes with mild patchy bibasilar atelectasis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Ankle injury, Transfer
Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Fall on and from ladder, initial encounter
temperature: 98.3
heartrate: 75.0
resprate: 16.0
o2sat: 99.0
sbp: 131.0
dbp: 80.0
level of pain: 6
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for application of an external fixation device, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the RLE extremity, and will be
discharged on aspirin for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
chest pain, shortness of breath, hemoptysis
Major Surgical or Invasive Procedure:
MIBI ___
History of Present Illness:
Mr. ___ is a ___ male with history of CAD,
hypertension, diabetes, CKD on ___ dialysis
last yesterday, presents with back pain radiating to his chest
associated with shortness of breath.
Patient notes exertional shortness of breath, orthopnea and low
volume hemoptysis as well as epistaxis for the past month. This
is associated with chest pain on exertion which he states is a
radiation of his back / left flank pain but also associated with
shortness of breath and present with exertion and feels more
severe than his prior episodes of MI. He states he has had this
same back pain every time he has dialysis since he began
dialysis last month. Additionally, he was recently admitted ___
weeks ago for flash pulmonary edema in the setting of
hypertensive emergency and NSTEMI. He denies known fevers or
chills. He notes a 20 pound weight loss but this is in the
setting of starting HD recently. He has had a mild mostly
nonproductive cough but associated with occasional blood tinged
sputum.
In the ED:
VS: 98.0, 82, 154/63, 18, 100% RA
ECG: nonischemic
PE: CTAB, nonlabored breathing, no edema
Labs: troponin 0.02 -> 0.03, BNP 2810
Imaging: CTA chest negative for PE but notable for enlarging
pulmonary nodules concerning for malignancy
Impression: rule out angina, concern for malignancy admit for
pharm nuc stress test and bronch with biopsy
Interventions: home meds
Past Medical History:
PAST MEDICAL HISTORY:
=======================
1. CARDIAC RISK FACTORS
- Diabetes complicated by retinopathy, nephropathy
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD
- ___ (EF 55%)
3. OTHER PAST MEDICAL HISTORY
- Diverticulosis
- Vitamin D deficiency
- PAD (peripheral artery disease)
- Anemia
- Renal artery stenosis
- CKD V
- Obesity
- Secondary hyperparathyroidism of renal origin
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. History of DMII in brothers.
Physical Exam:
ADMISSION EXAM:
VS: 98.6, 160/69, 83,18, 100% RA
Gen - tired appearing, NAD
Eyes - PERRLA with mild conjunctival injection
ENT - MMM
Heart - RRR, no r/m/g
Lungs - scant bibasilar rales otherwise CTAB, unlabored
breathing
Abd - soft ntnd
Ext - no pedal edema
Skin - no rashes noted on cursory skin exam
Vasc - WWP
Neuro - A&Ox4
Psych - pleasant, calm cooperative
Discharge Exam:
Afebrile, aVSS
Breathing comfortably on room air. Ambulatory sats 92-96% on RA.
Lungs clear to auscultation bilaterally.
Pertinent Results:
ADMISSION LABS:
___ 12:06AM BLOOD WBC-7.7 RBC-2.72* Hgb-7.8* Hct-25.7*
MCV-95 MCH-28.7 MCHC-30.4* RDW-14.4 RDWSD-47.5* Plt ___
___ 12:06AM BLOOD Neuts-73.5* Lymphs-13.1* Monos-10.7
Eos-1.3 Baso-0.7 Im ___ AbsNeut-5.63 AbsLymp-1.00*
AbsMono-0.82* AbsEos-0.10 AbsBaso-0.05
___ 07:10AM BLOOD ___ PTT-33.4 ___
___ 12:06AM BLOOD Glucose-229* UreaN-38* Creat-3.8* Na-131*
K-4.0 Cl-87* HCO3-26 AnGap-18
___ 12:06AM BLOOD ALT-12 AST-19 AlkPhos-87 TotBili-0.3
___ 12:06AM BLOOD cTropnT-0.02* proBNP-2810*
___ 07:10AM BLOOD Albumin-3.9 Calcium-9.1 Phos-4.6* Mg-2.4
Iron-44*
___ 07:10AM BLOOD calTIBC-241* VitB12-619 Folate->20
Ferritn-1446* TRF-185*
___ 07:20AM BLOOD 25VitD-40
___ 07:00AM BLOOD ANCA-NEGATIVE B
___ 07:00AM BLOOD CRP-54.6*
No labs on day of discharge
MIBI:
1. Partially reversible, medium sized, moderate severity
perfusion defect
involving the RCA territory.
2. Normal left ventricular cavity size and systolic function.
CT-A chest:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Multiple, spiculated, nodules and masses throughout the mid
right middle
and lower lobes, in a perilymphatic distribution, show minimal
surrounding
ground-glass with air bronchograms in multiple areas. There are
few areas of airway obliteration beyond the subsegmental level.
Largest mass is seen in the medial right lung base, measuring
4.1 x 2.2 x 1.6 cm. Neoplastic etiology is favored for these
findings, much less likely infectious. Recommend tissue
diagnosis for further evaluation.
3. Large right hilar soft tissue adenopathy, likely neoplastic
in etiology. This area could also be considered for tissue
diagnosis.
4. Multiple additional calcified mediastinal lymph nodes and
calcified
granulomas throughout the lungs, likely sequela of prior
granulomatous
disease.
Microbiology:
- AFBs negative x3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Losartan Potassium 100 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
8. sevelamer CARBONATE 1600 mg PO TID W/MEALS
9. Furosemide 40 mg PO EVERY OTHER DAY
10. Ranitidine 150 mg PO BID
11. Calcitriol 0.25 mcg PO 3X/WEEK (___)
12. HydrALAZINE 50 mg PO TID
13. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth DAily Disp #*30 Capsule Refills:*0
3. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
4. TraMADol 50 mg PO Q4H:PRN BREAKTHROUGH PAIN
RX *tramadol 50 mg 1 tablet(s) by mouth Q4 Disp #*30 Tablet
Refills:*0
5. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
6. Furosemide 40 mg PO 4X/WEEK (___)
7. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. amLODIPine 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Calcitriol 0.25 mcg PO 3X/WEEK (___)
12. Losartan Potassium 100 mg PO QHS
13. Multivitamins 1 TAB PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
16. Ranitidine 150 mg PO BID
17. sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right sided lung opacities with lymphadenopathy
Chest pain, stable coronary artery disease
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough, shortness of breath// Pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior comparisons, most recent chest radiograph from ___ chest radiographs ___, and thirty-first.
FINDINGS:
Both the bulk of the right hilum and multiple nodular lesions in the right
lung have increased since ___. Chest radiographs read in conjunction
with subsequent chest CTA. Findings are pose Ling. The CT findings suggest
malignancy, but the rapid progression would be very unusual
IMPRESSION:
Increased in conspicuity of the patchy opacities in the lung bases, right
greater than left, which may reflect sequela of recurrent aspiration and
possible underlying pneumonia. Combination of peripheral unilateral lung
nodules and central adenopathy progressing over 2 weeks could be unusual
infection or rapidly progressive malignancy such as lymphoma.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with chest pain radiating to back, tender thoracic
spine// eval for aortic dissection, thoracic spine injury
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 33.7 cm; CTDIvol = 12.6 mGy (Body) DLP = 423.1
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 1.2 s, 0.5 cm; CTDIvol = 6.6 mGy (Body) DLP = 3.3
mGy-cm.
Total DLP (Body) = 428 mGy-cm.
COMPARISON: Prior PET-CT from ___
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is no axillary or supraclavicular
lymphadenopathy. There are multiple, calcified, enlarged mediastinal lymph
nodes, measuring up to 1.7 cm in the subcarinal station (series 301; image
106). There is no left hilar lymphadenopathy. Soft tissue density nodules
are seen in the right hilum, which surround, but did not appear to invade the
right hilar pulmonary vasculature (series 601; image 28, series 301; image
98).
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is moderate background centrilobular emphysema, most
notable at the bilateral lung apices. There is lingular and left basilar
atelectasis without left lung focal consolidation. There are multiple,
spicular, nodules and masses throughout the right middle and lower lobes, in a
perilymphatic distribution. These show minimal surrounding ground-glass with
air bronchograms in multiple areas. There are also a few areas of airway
obliteration beyond the subsegmental level. Largest mass is seen in the
medial right lung base measuring 4.1 x 2.2 x 1.6 cm (series 601; image 36,
series 301; image 160). Neoplastic etiology is favored for these findings,
much less likely infectious. Recommend tissue diagnosis for further
evaluation.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable. There is a
small hiatal hernia. There is nonspecific thickening of the bilateral adrenal
glands.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Multiple, spiculated, nodules and masses throughout the mid right middle
and lower lobes, in a perilymphatic distribution, show minimal surrounding
ground-glass with air bronchograms in multiple areas. There are few areas of
airway obliteration beyond the subsegmental level. Largest mass is seen in
the medial right lung base, measuring 4.1 x 2.2 x 1.6 cm. Neoplastic etiology
is favored for these findings, much less likely infectious. Recommend tissue
diagnosis for further evaluation.
3. Large right hilar soft tissue adenopathy, likely neoplastic in etiology.
This area could also be considered for tissue diagnosis.
4. Multiple additional calcified mediastinal lymph nodes and calcified
granulomas throughout the lungs, likely sequela of prior granulomatous
disease.
RECOMMENDATION(S): Recommend tissue diagnosis of likely neoplastic process in
the right lung.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Other chest pain, Dyspnea, unspecified, Chronic kidney disease, unspecified
temperature: 98.5
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 143.0
dbp: 43.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ male with history of CAD,
hypertension, diabetes, CKD on HD MWF, presented with back pain
radiating to his chest associated with shortness of breath. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Allopurinol
Attending: ___.
Chief Complaint:
Chest pain, acute renal failure, dyspepsia, cramps
Major Surgical or Invasive Procedure:
Upper GI endoscopy, exercise stress test, Echocardiogram.
History of Present Illness:
___ with pmh significant for morbid obesity, OSA, HTN, CAD s/p
MI with stenting, gout, who presented to his PCP office for
follow evaluation of his serum chemistries which showed
worsening renal failure. He went into his PCP's office today for
laboratory evaluation. He was referred to the emergency
department secondary to the patients elevated creatinine.
Patient was recently admitted for hyperkalemia and at that time
his lisinopril was held. Upon review of systems, the patient
endorses 8 lb weigh loss from his lasix, nausea, dyspepsia,
dysphagia for solids, diffuse muscle cramps lasting for a few
seconds, right knee pain and back pain. He notes that he has
been constipated recently. He denies any chest pain or shortness
of breath. Patient denies decreased exercise tolerance. The
patient denies PND, orthopnea, ___ swelling. He notes that he has
recently stopped his lisinopril 8 days ago. He notes that he has
been using nsaid's for pain and he takes no more than 4 in a
day.
Past Medical History:
- Obesity
- DM 2
- Obstructive sleep apnea
- Status post corneal transplant ___
- Obesity
- High cholesterol
- CAD - h/o MI
- Gout
- Chronic kidney disease
- Dermatitis
- HTN
Social History:
___
Family History:
Mother passed away from renal failure, family history of CAD,
pancreatic cancer, atherosclerosis
Physical Exam:
Vital signs: 98.6, 146/75, HR 80, 95% RA, ___ 160.
Gen: NAD, Obese, conversant, missing left eye
Eyes: EOML, PERRL
Neck: no LAD, no JVD
Cardiovascular: regular rate, nl s1 s2. No murmurs, rubs or
gallops.
Extremities: no c/c/e
Respiratory: CTA ___
GI: Soft, obese, rotund, nt/nd, no rebound or guarding. Bowel
sounds+.
Neuro: AA0x3, CN ___ intact, motor ___ ___.
Pertinent Results:
Studies)
Echocardiogram:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
root is mildly dilated at the sinus level. The ascending aorta
is mildly dilated. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
Renal Ultrasound:
The right kidney measures 12.8 cm and the left kidney measures
12.1
cm. There is no hydronephrosis. No stone or cyst or solid mass
is seen in
either kidney. The pre-void bladder is unremarkable but is only
minimally
distended.
Incidentally noted on limited images of the right upper quadrant
the liver is diffusely echogenic consistent with fatty
infiltration.
Exercise Stress Test:
XERCISE RESULTS
RESTING DATA
EKG: SINUS, IVCD
HEART RATE: 64BLOOD PRESSURE: 144/74
PROTOCOL GERVINO - TREADMILL
STAGETIMESPEEDELEVATIONHEARTBLOODRPP
(MIN)(MPH)(%)RATEPRESSURE
___
___
___
TOTAL EXERCISE TIME: 10% MAX HRT RATE ACHIEVED: 90
SYMPTOMS:NONE
INTERPRETATION: This ___ yo man with 3V CAD s/p MI ___ and CKD
was
referred to the lab from the floor for evaluation of chest
discomfort.
The patient exercised for 10 minutes of a Gervino protocol and
was
stopped for fatigue. The peak estimated MET capacity was 5.2,
which
represents a poor exercise tolerance for his age. There were no
reports
of chest, back, neck, or arm discomforts during the study. At
peak
exercise, there was 0.5-1 mm horizontal ST segment depression
with
biphasic T waves in lead V6 only, returning back to baseline by
10
minutes of recovery. Rhythm was sinus with rare isolated APBs.
The heart
rate response was blunted in the presence of beta blockade. The
blood
pressure response was appropriate during exercise and recovery.
IMPRESSION: No anginal type symptoms or diagnostic EKG changes
at a high
cardiac demand and poor functional capacity.
--------------
Upper GI Endoscopy:
Esophagitis in the gastroesophageal junction (biopsy)
Friability and erythema in the antrum and duodenal bulb
compatible with gastritis (biopsy) and duodenitis. Otherwise
normal EGD to third part of the duodenum
--------
___ 08:00AM BLOOD WBC-7.4 RBC-3.76* Hgb-11.1* Hct-32.3*
MCV-86 MCH-29.6 MCHC-34.5 RDW-13.7 Plt ___
___ 07:48AM BLOOD WBC-8.7 RBC-3.81* Hgb-11.4* Hct-31.9*
MCV-84 MCH-29.9 MCHC-35.7* RDW-14.1 Plt ___
___ 12:45PM BLOOD WBC-9.5 RBC-3.94* Hgb-12.2* Hct-32.8*
MCV-83 MCH-30.9 MCHC-37.1* RDW-13.6 Plt ___
___ 08:00AM BLOOD ALT-26 AST-22 AlkPhos-103 TotBili-0.4
___ 08:09PM BLOOD cTropnT-<0.01
___ 12:45PM BLOOD cTropnT-<0.01
___ 08:00AM BLOOD Albumin-4.1 Calcium-9.2 Phos-3.1 Mg-1.9
___ 10:03AM URINE Hours-RANDOM UreaN-1221 Creat-181 Na-37
K-47 Cl-28 TotProt-13 Phos-84.1 Uric Ac-38.0 Prot/Cr-0.1
___ 10:03AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:42PM URINE Color-Straw Appear-Clear Sp ___
___ 10:03AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
##H Pylori: PENDING######
Medications on Admission:
Norvasc 10mg qd
Metoprolol xl 50mg qam
Lipitor 20mg
Euloric 40mg
Byetta 10mg
Iron 325mg once a day
MVI
Metformin 1g''
ASA 81'
Lasix po 20mg''
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Byetta 10 mcg/0.04 mL Pen Injector Sig: One (1) injection
Subcutaneous twice a day: Before meals .
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Esophagitis
2. Gastritis
3. Acute kidney injury secondary to dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with intermittent chest pain.
COMPARISONS: None available.
FINDINGS:
Frontal and lateral views of the chest demonstrate normal lung volumes. There
is no pleural effusion, focal consolidation, or pneumothorax. Hilar and
mediastinal silhouettes are unremarkable. Heart size is normal. There is no
pulmonary edema. Partially imaged upper abdomen is unremarkable. An old left
anterolateral fracture without displacement is noted along the eighth rib.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
INDICATION: ___ man with morbid obesity, diabetes, acute on chronic
renal failure.
COMPARISON: Renal ultrasound, ___.
FINDINGS: The right kidney measures 12.8 cm and the left kidney measures 12.1
cm. There is no hydronephrosis. No stone or cyst or solid mass is seen in
either kidney. The pre-void bladder is unremarkable but is only minimally
distended.
Incidentally noted on limited images of the right upper quadrant the liver is
diffusely echogenic consistent with fatty infiltration.
IMPRESSION:
1. No hydronephrosis.
2. The liver is incidentally noted to be diffusely echogenic consistent with
fatty infiltration. Other forms of liver disease and more advanced liver
disease including significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NAUSEA/MALIASE/WEAKNESS
Diagnosed with CHEST PAIN NOS, MYALGIA AND MYOSITIS NOS, NAUSEA, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.1
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 99.0
level of pain: 8
level of acuity: 3.0 | ___ year old male with morbid obesity (BMI 48), DMII, CAD ___
years s/p inferior wall myocardial infarction, OSA on bipap,
gout, who presents with acute on chronic renal injury, atypical
chest pain, cramps, and dyspepsia for workup of his various
sequalae.
1. Rule out acute coronary syndrome:
This is a patient with multiple risk factors for UA/NSTEMI. He
reported constant cramping throughout his body. This crampy
sensation would sometimes be in his legs and other times it
would be substernal. This pain "crampy" in nature and would go
away in ___ seconds. It was not related to exertion and there
were no known factors which would alleviate or exacerbate this
condition. Given his TIMI risk score of 3 which represents a 13%
risk at 14 days of: all-cause mortality, new or recurrent MI, or
severe recurrent ischemia requiring urgent revascularization, he
was ruled out for ACS.
-Serial EKG were performed. His EKGs were unchanged from prior
and there were no signs myocardial ischemia on EKG.
-He had two negative troponins.
- He was further evaluated with an treadmill EKG which did not
show EKG changes concerning for ischemia, nor did it reproduce
any angina.
-His TTE showed cardiomegaly with normal to mildly depressed
ejection fraction. There were no signs of any focal wall
motion/valvular anomalies.
Given that there were no dynamic EKG changes, with a negative
exercise stress, and a normal echo, with negative cardiac
enzymes suggests that his chest cramping was not ischemic in
nature.
2. Acute on chronic renal failure:
The patient presented with a serum creatinine of 2.4. Of note
this was unchanged since his previous admission approximately 10
days ago. As part of his work-up, we held his lasix, got a
urinalysis, urine electrolytes, renal ultrasound, and formal
renal consultation.
-By holding the patients lasix his creatinine dropped from 2.3
to 1.6 over the course of two days.
-His renal ultrasound showed no pathology or signs of
obstruction. (However, it did show a diffusely fatty liver
incidentally).
-Renal consult suggested that his acute kidney injury was
pre-renal in nature and suggested having the patient continue to
hold his ACE-I and only take 20mg of lasix once a day instead of
BID.
-He was discharged with lasix 20mg once a day and follow up with
outpatient nephrology.
3.Dyspepsia:
The patient complained heartburn, nausea, feeling like he was
"throwing up in his mouth," and dysphagia for solids but not
liquids.
-We stopped his indocin which we felt might be causing
irritation of the gastric mucosa.
-We also started the patient on a proton pump inhibitor.
-GI was consulted an a EGD was performed which showed gastritis.
A biopsy was taken for further evaluation.
-In addition he was tested for h-pylori. THIS RESULT IS STILL
PENDING******
-He has follow up with Dr. ___ as an outpatient.
4. Type 2 DM: While inpatient, we put Mr. ___ on a ___
sliding scale and stopped his metformin secondary to his poor
kidney function. As his renal function improved, Dr. ___
that the patient would be safe to resume taking his metformin
and ___ as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex
Attending: ___.
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with a history of arthritis, hypertension, and
diabetes mellitus, seronegative RA - p/w right flank pain. Pt
states that flank pain started 1 week ago, gradual onset, she
went to ___ clinic and given cipro for UTI. UA at
that time showed trace leuks, Since then the pain has
progressively worsened now ___ in right flank non-radiating,
sharp. No dysuria, hematuria. No bowel changes. Denies
f/c/cp/sob/abd pain.
Pt notably went to clinic because of the flank pain which
started somewhat acutely and had simultaneous oiliguria but more
frequent urination. Never had hematuria or dysuria and never had
these symptoms in the past. Notes very different from rheumatoid
arthritis flares int he past involving knees and sometimes her
elbows. Has never involved her hip. Furthermore, pt notes no
changes in activity or exercise, no recent travel, no changes in
medications. Pt has never had subjective fevers at home and is
unclear why she is having this severe sharp pain in her flank
radiating down to her buttocks and upper thigh. She has not had
midline back pain either upper or lower. She is still able to
walk with the pain although it is uncomfortable and notes that
she needs assistance sometimes given the pain but otherwise is
fully functional at home with ADLs. Pt notes that with effort,
she is able to lift herself from a supine position to sitting
and from sitting to standing but it is not easy for her given
the pain.
Pt has had a brief history ___ Cr 1.4 (baseline 0.6-1.0) and
this was concerning for possible renal injury from celecoxib
which she had taken for her RA in the past. Now she is on pred 5
and methotrexate injections. She has not seen her rheumatologist
for some time and notes that given lack of flares and controlled
pain, she has not required to see her rheumatologist. When she
saw her nephrologist for her ___, a renal ultrasound at that
time was done with no evidence of hydrnpehoriss or obstruction.
Repeat Cr shortly after celecoxib was discontinue and pt
encouraged to increase po intake, Cr trended down to 1.0-1.1
In the ED, initial VS were 97.9 HR95 BP 130/112 RR 16 100% RA.
Labs notable for hyponatremia Na 127, UA is contaminated but WBC
8 no bacteria. Pt noted severe pain and was given Tylenol. Given
concern of a stone in setting of no fever or leukocytosis, pt
underwent a CTU which did not show any abnormalities. A urine
culture was sent but additional labs including CRP, ESR, CK were
not done. Pt noted to have persistnet oliguria although
increased frequency of urination.
On the floors, pt was stable and able to walk around although
with difficulty. She is surrounded by her family who is able to
translate for her and notes that they are concerned about the
uncontrolled pain also are unclear that this is entirely due to
a urinary tract infection. Pt is not short of breath, no chest
pain, no other joint pain, no nausea, vomiting. No GI symptoms
overall and does not endrose decreased po intake despite her low
sodium and confirms that her diet has remained consistent.
Past Medical History:
diabetes mellitus
rheuatmoid arthritis (Seronegative)
acute kidney injury
hypertension
vertigo
Social History:
___
Family History:
No contributory family history of rheumatologic or renal
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.8 88 141/88 16 99% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: Right CVAT
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Unchanged
Pertinent Results:
ADMISSION LABS
___ 08:45AM BLOOD WBC-8.5 RBC-3.51* Hgb-10.9* Hct-33.2*
MCV-95 MCH-31.1 MCHC-32.8 RDW-13.6 RDWSD-46.3 Plt ___
___ 08:45AM BLOOD Glucose-166* UreaN-13 Creat-1.1 Na-129*
K-4.5 Cl-89* HCO3-21* AnGap-24*
___ 11:15AM BLOOD ALT-24 AST-32 AlkPhos-70 TotBili-0.3
___ 11:15AM BLOOD Lipase-75*
DISCHARGE LABS
___ 05:45AM BLOOD WBC-6.6 RBC-3.07* Hgb-9.6* Hct-28.7*
MCV-94 MCH-31.3 MCHC-33.4 RDW-14.1 RDWSD-47.5* Plt ___
___ 05:45AM BLOOD Glucose-152* UreaN-15 Creat-1.0 Na-132*
K-4.3 Cl-96 HCO3-25 AnGap-15
___ 05:45AM BLOOD Calcium-9.3 Phos-4.7* Mg-1.7
IMAGING
CXR: ___
IMPRESSION:
No acute cardiopulmonary process.
CTU: ___
IMPRESSION:
1. Cholelithiasis without gallbladder wall thickening or
pericholecystic
fluid. Correlate for clinical signs of cholecystitis.
2. Hepatic steatosis.
3. No acute bowel pathology.
4. Diverticulosis without evidence of active inflammation.
5. No evidence of nephrolithiasis or renal pathology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Lisinopril 20 mg PO DAILY
3. LOPERamide 2 mg PO DAILY:PRN GI upset
4. Meclizine 25 mg PO Q6H:PRN dizziness
5. ClonazePAM 0.25 mg PO BID:PRN vertigo
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Vitamin E 400 UNIT PO DAILY
13. pilocarpine HCl 5 mg oral TID
14. cevimeline 30 mg oral BID
15. Magnesium Oxide 400 mg PO ONCE
16. Methotrexate 25 mg SC 1X/WEEK (___) rheuamtoid arthritis
17. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
One bowel movement daily
RX *docusate sodium 100 mg 1 capsule(s) by mouth up to two times
daily Disp #*30 Capsule Refills:*0
2. TraMADol 25 mg PO BID:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth up to two times
daily Disp #*10 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. cevimeline 30 mg oral BID
5. ClonazePAM 0.25 mg PO BID:PRN vertigo
6. Ferrous Sulfate 325 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. LOPERamide 2 mg PO DAILY:PRN GI upset
10. Magnesium Oxide 400 mg PO ONCE Duration: 1 Dose
11. Meclizine 25 mg PO Q6H:PRN dizziness
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Methotrexate 25 mg SC 1X/WEEK (___) rheuamtoid arthritis
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. pilocarpine HCl 5 mg oral TID
17. PredniSONE 5 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. Vitamin E 400 UNIT PO DAILY
20.Outpatient Lab Work
ICD 276.1. hyponatermia
Please check Chem 10 on ___.
Attn: ___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Flank pain
Hyponatremia
Seronegative arthritis
Hypertension
Diabetes
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with question of pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
The lungs are well inflated and clear. Heart size and mediastinal contours
are normal. No pleural effusion or pneumothorax. Osseous structures are
intact.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with left flank pain // eval for kidney stone/appendcitiis
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 922 mGy-cm.
COMPARISON: Renal ultrasound from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates borderline low attenuation throughout,
compatible with hepatic steatosis. There is no evidence of focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder contains gallstones without wall thickening or surrounding
inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no nephrolithiasis or ureterolithiasis. There is no hydronephrosis.
There is no perinephric abnormality. There is no evidence of focal renal
lesions. There is no evidence of urothelial lesions. The distal ureters and
bladder are unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is
diverticulosis of the sigmoid colon without evidence of active inflammation.
The appendix is not visualized.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and adnexae are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no acute fracture. There is moderate facet arthropathy
throughout the lumbar spine. Symmetric sclerosis about the sacroiliac joints
bilaterally is likely degenerative. Widening of the left S1-S2 neural foramen
suggests underlying Tarlov cyst. No concerning osseous lesion.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Cholelithiasis without gallbladder wall thickening or pericholecystic
fluid. Correlate for clinical signs of cholecystitis.
2. Hepatic steatosis.
3. No acute bowel pathology.
4. Diverticulosis without evidence of active inflammation.
5. No evidence of nephrolithiasis or renal pathology.
Gender: F
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: R Flank pain, R Leg pain
Diagnosed with Hypo-osmolality and hyponatremia
temperature: 97.9
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 130.0
dbp: 112.0
level of pain: 5
level of acuity: 3.0 | Pt is a ___ with history notable for seronegative arthritis,
hypertension, diabetes here for severe flank pain x 1 week and
oliguria/increased urinary frequency with CTU negative for
hydronephrosis or stone concerning, no radiographic evidence for
pyelonephritis. UA was negative, UCx without growth on
discharge.
#Flank pain: GU vs MSK etiology. Patient has been afebrile,
without leukocytosis, and questionable urinalysis given
contaminant in ED urine sample and outside clinic UA with trace
leuks s/p 6 days of cipro. Urinary symptoms point towards GU
etiology although imaging is negative. However, pt does have
history of seronegative arthritis and has required pred and mtx
for pain control. Given that the flank pain radiates down
buttocks and upper thighs it was felt her pain was likely MSK.
CRP elevated at 7. We treated pain with 1 dose oxycodone 5 mg,
patient slept well and on morning of discharge was no longer in
pain. On day of discharge, patient denied hip pain, flank pain
or difficult urinating.
#hyponatremia: notable new hyponatremia to 127, has been low as
131 on prior check given ___ for celecoxib however pt does
endorse somewhat low po intake today, urine lytes suggest
possible SIADH etiology. Pt given IVF in ED and appears to have
worsened. On morning of discharge, Na+ 132 that improved after
pain control and PO intake.
To follow the hyponateremia, patient is scheduled for repeat
Chem10 on ___ with her PCP.
#seronegative arthritis: controlled outpatient with pred5 mg and
methotrexate injections
#hypertension: restarted lisinopril upon discharge. will hold
for now given possibility of infection although vitals stable
#diabetes: restarted metforming 1000mg
#anxiety: continued clonazepam 0.5 prn
#nutrition: continued iron sulfate, magnesium oxide, vitamin E,
vitamin D, fish oil capsules
======================
Transitional Issues
=======================
- Should she remain on meclizine
- F/u hyponateremia, ensure sodium is stable
- close follow up with rheumatology, primary care
- DNR/DNI (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Blurred vision/LUE paresthesias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o female transferred from ___ with right
parietal occipital edema on head CT concerning for an underlying
lesion. She states that she experienced a headache, transient
blurred vision and numbness, tingling weakness of the right
upper
extremity yesterday and occasionally into the left upper
extremity over the past two days. These symptoms came on quickly
and self resolved both days after several hours. She became
concerned and presented to ___ today at which time
she underwent a CT of the head which was concerning for a brain
lesion. She was transferred to ___ for further evaluation.
At the time of the physical examination, she denies headache,
dizziness, blurred vision, diplopia, chest pain, shortness of
breath, nausea, vomiting, fever, chills or parasthesias and
weakness of the extremities bilaterally. She endorses a cough
which has been present for several days.
Past Medical History:
Hypertension
s/p left shoulder surgery
Social History:
___
Family History:
Denies family history of brain lesions or cancer.
Physical Exam:
T: 99.5 BP: 108/76 HR: 66 RR: 18 O2Sats 95% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3mm bilaterally. EOMs intact throughout.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch bilaterally throughout all four
extremities.
Handedness: Right
ON DISCHARGE: Non-focal
Pertinent Results:
Pertinent results available in OMR
Medications on Admission:
Lisinopril 10mg-HCTZ 12.5mg PO daily
ASA 81mg PO daily, last dose ___
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4GM acetaminophen in 24 hours
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth Every evening Disp
#*30 Tablet Refills:*0
3. Enoxaparin Sodium 0 mg SC DAILY
Continue taking until INR for Coumadin is therapeutic (___) for
24 hours
RX *enoxaparin 80 mg/0.8 mL 0.8 mL SC Daily Disp #*5 Syringe
Refills:*0
4. Nicotine Patch 14 mg TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour Daily Disp #*14 Patch
Refills:*0
5. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ischemic infarction
Occlusive thrombus in the left brachial artery
Discharge Condition:
*
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR spectroscopy
INDICATION: ___ year old woman with nonenhancing right occipital lesion// eval
for tumor vs stroke work up. please include DWI sequences as well if able.
TECHNIQUE: Axial FLAIR and diffusion images of the brain were performed.
Subsequently, MR spectroscopy images were obtained on a 3 tesla magnet with
144 TE with voxel overlying the occipital lobes with acquisition of multi
voxel spectroscopy. In addition, single voxel spectroscopy was performed with
voxel placed over the right occipital lobe. Findings are based on
interpretation of all images.
COMPARISON: MR ___
FINDINGS:
MR ___:
The provided axial FLAIR and diffusion images demonstrate interval evolution
of slow diffusion within the right occipital lobe with associated FLAIR
hyperintensity. The ventricles are normal in size without mass effect or
midline shift. There are a few nonspecific subcortical FLAIR
hyperintensities, likely a sequela of chronic small vessel ischemic disease.
MR spectroscopy:
Single voxel spectroscopy with voxel placed over the region of signal
abnormality in the right occipital lobe demonstrates elevated lactate peak at
1.3 ppm (7:1). Multi voxel spectroscopy demonstrates nonspecific spectroscopy
pattern with majority of the proximal small in the region of interest
demonstrating no significant elevation in choline to NAA ratio.
IMPRESSION:
Evolution of signal abnormality in the right occipital lobe with corresponding
single voxel spectroscopy demonstrating lactate peak. Constellation of
findings are most suggestive of evolving infarction in the distribution of the
right posterior cerebral artery rather than an underlying malignancy.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with new suspected right PCA territory
infarct// eval of head/neck vessels for stroke work up
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 4.5 s, 35.5 cm; CTDIvol = 11.4 mGy (Body) DLP = 402.8
mGy-cm.
3) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 17.8 mGy (Body) DLP =
8.9 mGy-cm.
Total DLP (Body) = 412 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: MR head with and without ___, outside CT head ___, CT chest ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is redemonstration of focal hypodensity within the right
parieto-occipital lobe corresponding to findings on recent MRI and similar to
prior CT head from ___. There is prominence of the ventricles and
sulci related to diffuse parenchymal volume loss. There is no evidence of
mass effect or midline shift. There is no evidence of intracranial
hemorrhage. There is mild mucosal thickening of the bilateral ethmoid air
cells. The remaining paranasal sinuses appear clear. The bilateral mastoid
air cells appear clear.
CTA HEAD:
The bilateral anterior middle cerebral arteries appear patent. The bilateral
posterior cerebral arteries appear patent. The basilar artery and bilateral
vertebral arteries appear patent. There is a dominant right vertebral artery.
The bilateral intracranial internal carotid arteries appear patent. There is
no evidence of dissection. The dural venous sinuses appear patent.
CTA NECK:
There are mild vascular calcifications of the aortic arch. There is a linear
filling defect along the lateral margin of the aortic arch (03:27), difficult
to visualize on the coronal sagittal reconstruction images, and not seen on
the recent CT chest ___, likely artifactual. There is
noncalcified plaque causing mild luminal narrowing of the proximal left
subclavian artery (3:65). There is a right dominant vertebral artery. The
bilateral vertebral arteries appear patent. The bilateral common carotid
arteries and internal carotid arteries appear patent without internal carotid
artery stenosis by NASCET criteria.
OTHER:
The thyroid gland appears unremarkable. There is moderate centrilobular
emphysema. There are multilevel degenerative changes of the cervical spine.
There is no evidence of lymphadenopathy per size criteria.
IMPRESSION:
1. Stable right parieto-occipital lobe hypodensity, likely corresponding to
evolving subacute infarction. No evidence of intracranial hemorrhage.
2. Patency of the major intracranial vasculature without stenosis, occlusion,
or aneurysm.
3. Patency of the bilateral carotid arteries and vertebral arteries, without
internal carotid artery stenosis by NASCET criteria.
4. Linear defect of the lateral aspect of the left carotid bulb due to a
carotid web, an incidental finding.
5. Probable artifact creating linear filling defect within the lateral margin
of the aortic arch, not seen on the recent CT chest ___.
6. Noncalcified plaque resulting in mild luminal narrowing of the proximal
left subclavian artery.
7. Moderate centrilobular emphysema.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with LUE pain x3 days, please evaluate for
DVT.// Evaluate for DVT in LUE, patient is complaining of constant general
pain in the bicep/tricep area
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
There is occlusive thrombus in the left brachial artery.
IMPRESSION:
-Occlusive thrombus in the left brachial artery.
-No evidence of deep vein thrombosis in the left upper extremity.
NOTIFICATION: The findings were discussed by Dr. ___ with ___
on the telephone on ___ at 2:20 pm, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CTA torso
INDICATION: ___ year old woman with L arm pain found to have occlusive
thrombus in the L brachial artery on Ultrasound// Include L arm to evaluate
anatomy. Evaluate for source of thrombus causing occlusive thrombus in the L
brachial artery such as aortic plaque.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 815 mGy-cm.
COMPARISON: CT chest ___.
CT abdomen and pelvis ___.
Left upper extremity Doppler ultrasound ___
FINDINGS:
VASCULAR:
There is moderate atherosclerotic disease of the abdominal aorta and bilateral
common iliac arteries. There is mild atherosclerotic disease in the takeoff
of the left subclavian artery, left common carotid artery, and right
brachiocephalic trunk. There is no evidence of occlusion of the thoracic
aorta, abdominal aorta and its major branches.
Limited evaluation of the left arm, but there is an abrupt cutoff in the left
brachial artery (series 3: 74-75) with reconstitution of flow distally likely
corresponding to focal thrombus seen on left upper extremity ultrasound ___
CHEST:
HEART AND VASCULATURE: Although not optimized for evaluation of the pulmonary
vasculature, there is no evidence of a filling defect of the pulmonary vessels
to the lobar level. Heart is normal in size. There is no pericardial
effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild biapical scarring. There is severe centrilobular
emphysema. Punctate micro nodules in the right upper and left lower lobes
(series 3:28, 47) are again seen, minimally changed in appearance from CT
chest ___. Calcified granulomas in the right upper lobe (series
3:57) and left lower lobe (series 3: 83) are again noted. There is no
consolidation. Airways are patent to the subsegmental levels.
BASE OF NECK: The thyroid is unremarkable
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is a segment IV hypoattenuated focus measuring 1.5 cm(series 3:96) and a
subcentimeter hypoattenuated focus in the left lobe (series 3:99) which is too
small to characterize but likely represents a biliary hamartoma versus a
simple cyst. There is no intra or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. A splenule is noted.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is a wedge shaped area of hypoattenuation in the upper pole of
the right kidney (series 3:127) which is new from ___. Heterogeneity
of the left renal parenchyma is minimally changed from ___. There is
no definite evidence of invasion into the renal pelvis. There is no
hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: Oral contrast is seen to the level of the rectum. The
stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal. There is no free intraperitoneal fluid or
free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mild to moderate atherosclerotic disease of the takeoff of the left
subclavian artery, left common carotid artery, and right brachiocephalic
trunk. There is moderate atherosclerotic disease of the abdominal aorta.
There is no evidence of occlusion, thrombus, or a large plaque of the
thoracoabdominal aorta and its major branches.
2. Wedge-shaped area of hypoattenuation in the upper pole of the right kidney
(series 3:127) which is new as compared to CT abdomen pelvis ___.
This could represent infarction or focal pyelonephritis.
3. Heterogeneous enhancement of the left kidney is grossly unchanged from CT
abdomen and pelvis ___ and most suggestive of pyelonephritis.
Follow-up CT is recommended following treatment to ensure improvement or
resolution.
4. Limited evaluation of the arm, but there is an abrupt cutoff in the left
brachial artery (series 3: 74-75) with reconstitution of flow distally likely
corresponding to focal thrombus seen on left upper extremity ultrasound ___.
NOTIFICATION: The findings were discussed by Dr. ___ with NP ___
___ on the telephone on ___ at 8:56 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with blurry vision, numbness, headache, right
upper extremity weakness with recent CT demonstrating right parieto-occipital
lobe edema. Evaluate for underlying mass.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 5 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT head ___
FINDINGS:
There is slow diffusion within the right parieto-occipital lobe with
associated FLAIR hyperintensity. There is no enhancing mass or abnormal
enhancement. There is no evidence of intracranial hemorrhage. There are no
other areas of diffusion abnormality. The ventricles are normal in size
without mass effect or midline shift. The dural venous sinuses appear
patent on the postcontrast images. There is mild mucosal thickening of the
bilateral ethmoid air cells. The remaining paranasal sinuses appear clear.
There is minimal fluid opacification of the bilateral mastoid air cells. The
orbits appear unremarkable. The visualized soft tissues appear unremarkable.
IMPRESSION:
1. Acute to early subacute infarction in the distribution of the right
posterior cerebral artery.
2. No evidence of intracranial hemorrhage. No evidence of enhancing mass or
abnormal enhancement.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:39 am, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ year old woman with new brain mass.
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 1.9 s, 30.7 cm; CTDIvol = 5.6 mGy (Body) DLP = 172.2
mGy-cm.
2) Spiral Acquisition 4.3 s, 68.7 cm; CTDIvol = 7.4 mGy (Body) DLP = 510.0
mGy-cm.
3) Spiral Acquisition 1.8 s, 29.2 cm; CTDIvol = 5.6 mGy (Body) DLP = 164.0
mGy-cm.
4) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 13.9 mGy (Body) DLP =
7.0 mGy-cm.
Total DLP (Body) = 853 mGy-cm.
COMPARISON: MR examination of the head from ___. Reference CT
examination from ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There are 2 hepatic hypodensities with the largest in segment IV measuring 1.3
cm, likely compatible with hepatic cysts versus biliary hamartomas. There is
no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is heterogeneity of the left renal parenchyma with multiple
foci of cortical hypoenhancement and mild adjacent fatty stranding (series 3,
image 64, 66). No dominant lesion is seen. No definite invasion into the
renal pelvis is seen. There is no hydronephrosis.
The right kidney is of normal size with normal nephrogram. There is no
evidence of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. There is an accessory left renal artery (series 3, image 62).
BONES: Degenerative changes are seen in the lumbar spine most notable for mild
retrolisthesis L2 on L3.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Multiple heterogeneous foci of hypoenhancement throughout the left renal
cortex with mild stranding, most suggestive of pyelonephritis. Given the
absence of a definite malignancy on recent head MR and presence of a markedly
elevated WBC, infection remains the likely cause. An infiltrative neoplasm
can be considered, but is less likely in this clinical setting. Follow-up CT
is recommended following initial treatment to ensure improvement/resolution.
2. No abdominopelvic lymphadenopathy.
Radiology Report
EXAMINATION: CT CHEST WITH CONTRAST
INDICATION: ___ woman with "new brain mass" . Assess for primary
malignancy. Please note, overnight brain MRI revealed acute to early subacute
infarction rather than the presence of an intracranial malignancy.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Mild cardiomegaly. No pericardial effusion. The
thoracic aorta is normal in caliber. Mild aortic and great vessel origin
atherosclerosis. Minimal coronary atherosclerosis. The main pulmonary artery
is normal in caliber. No central pulmonary embolus.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Mild biapical scarring. Severe centrilobular emphysema. Few
punctate micro nodules, right upper and lower lobes (series 302, images 59,
108, 168). Calcified granulomas in the right upper and left lower lobes
(series 4, images 116 and 169). The airways are patent to the subsegmental
level. Mild diffuse bronchial wall thickening suggests chronic airway
inflammation.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Heterogeneous left renal parenchyma with foci of hypoenhancement and
adjacent fat stranding. Please refer to separate report for same-day CT
abdomen/pelvis for description of the abdominal findings.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Left pyelonephritis.
2. No evidence of intrathoracic malignancy.
3. Severe centrilobular emphysema.
4. Chronic small airway inflammation.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:41 am, less than 15 minutes
after discovery of the findings.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: Headache, R Hand numbness, Transfer
Diagnosed with Other specified disorders of brain
temperature: 99.5
heartrate: 66.0
resprate: 18.0
o2sat: 95.0
sbp: 108.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | ___ yo female patient admitted to Neurosurgery for further work
up after presenting with LUE paresthesias and blurred vision.
Head CT showed right occipital edema concerning for underlying
lesion.
#Brain lesion/Acute ischemic stroke
Brain MRI with and without contrast was done. This showed a
non-enhancing lesion concerning for possible PCA infarct.
Neurology and Neurooncology were consulted and MRS was ordered,
stroke workup ongoing. Patient was started on Atorvastatin per
neurology recommendations. TTE was unremarkable. CTA showed
patency of the major intracranial vasculature without stenosis,
occlusion, or aneurysm and patency of the bilateral carotid
arteries and vertebral arteries, without internal carotid artery
stenosis by NASCET criteria. MRS ___ suggested evolving
infarction in the distribution of the right posterior cerebral
artery rather than an underlying malignancy. Neurology was
notified and cleared the patient for discharge with follow-up as
outpatient including an appointment with Dr. ___
___ monitor, and TEE. Her home Aspirin 81mg was resumed on
___. Signs and symptoms of stroke were reviewed with the patient
and her family with a ___ interpreter present in the room
prior to discharge. Due to blood clot found in brachial artery,
her Aspirin was stopped and she was transitioned to Lovenox
bridge to Coumadin. All questions and concerns regarding imaging
results and follow-up plan were answered with the interpreter at
this time.
#Pyelonephritis/Leukocytosis
On admission the patient was noted to have Leukocytosis of 23.
She was afebrile and urinalysis was negative. CT torso for
metastatic work up showed left pyelonephritis. Urine culture
was ordered and Cipro was started after Urine Cx was obtained.
MERIT service consulted for evaluation however given that the
patient is afebrile and UA negative, recommend following up on
urine culture. On ___, urine culture resulted as negative,
Cipro discontinued. Patient was monitored closely and denied
back pain, urinary symptoms, fevers, chills with ___
interpreter present. She was advised to follow-up with her PCP
after discharge.
#Occlusive thrombus in the left brachial artery:
A LUE ultrasound was done for complaints of general pain in the
left bicep/tricep area. The ultrasound showed occlusive thrombus
in the left brachial artery. Vascular surgery was consulted and
recommended CTA torso including the LUE to evaluate for causes
of thrombus such as aortic plaque. The CTA torso showed new
wedge shaped lesion in R kidney suggestive of infarct and some
atherosclerosis but no clear source. She was started on Lovenox
and Warfarin as noted above. Due to concern for hypercoagulable
state, associated labs were sent with other arranged to be
collected as outpatient. She was directed to follow up with
Hematology as outpatient to review lab results. She is ordered
for repeat LUE US in 1 month and follow up in ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspena on exertion
Major Surgical or Invasive Procedure:
Right and left heart cath ___
TEE without cardioversion ___
History of Present Illness:
___ referred to ED by PCP for volume overload and HTN
management. Was seen by PCP last week as new patient (first time
seeing an MD in ___ years) with dyspnea on exertion, progressive,
over several months. Found to be in Afib with rapid ventricular
response and signs of CHF. Started on furosemide, aspirin,
metoprolol. Returned to ___ on day of admission for further med
titration and to begin anticoagulant.
Pt reported to PCP that new medications made his abdomninal
distention felt worse and he stopped the meds as so ___. He
believes he lost a few pounds, weighing on his scale this am
175.9. He did not have lightheadedness or dizziness.
He feels stable to worse re: dyspnea, with more difficulty
wearing his 15 lb equipment/gun belt at work (works for ___
and ___). The patient is normally an "avid jogger,"
running regularly and completing one marathon per year. He now
struggles to climb stairs.
Labwork from first PCP visit is significant for mild elev
transaminase & LDH, and A1c in diabetic range (6.8). Also mild
normocytic anemia.
Echocardiogram report from ___ reported this am shows:
IMPRESSION: EF ___ Marked symmetric left ventricular
hypertrophy with normal cavity size and severe biventricular
hypokinesis in a pattern most suggestive of a non-ischemic
cardiomyopathy. Moderate pulmonary artery hypertension.
Mild-moderate mitral regurgitation. Mild-moderate tricuspid
regurgitation. Prominent bilateral pleural effusions. Mildly
dilated ascending aorta. Increased PCWP. In the absence of a
history of prominent systolic hypertension, an infiltrative
process (e.g., amyloid) should be considered.
In the ED, initial vitals were T98.1 HR115 BP145/77 RR18 100%RA.
Labs notable for proBNP of 6985, K of 5.6 (moderately
hemolyzed), Cr 1.3. Chest xray showed cardiomegaly, small
bilateral pleural effusions, mild pulmonary edema. Given aspirin
325mg, Diltiazem 70mg (60 PO, 10 IV), furosemide 20mg IV x1.
Admitted for further management. Pt endorses filling two urinals
since getting lasix, UO not recorded.
Denies fever, chills, cp, sob at rest, abd pain, n/v/d, dysuria.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Past Medical History:
DOE
Carpal Tunnel Syndrome
Partial thumb amputation
Social History:
___
Family History:
Father had diabetes. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory. One younger sister, estranged, died of
unknown causes. 4 other siblings are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T98.6, BP123/83, HR93, RR16, O296RA
General: well-appearing man lying in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: JVD to mandible at 60 degrees
CV: irregularly irregular, no m/r/g appreciated, normal S1S2
Lungs: mild bibasilar crackles present, no wheezing appreciated
Abdomen: soft, NT, ND, +BS
Extr: no c/c/e, 2+ DP pulses bilaterally, missing portion of
left thumb, 2+ pitting edema in ___
Neuro: A&Ox3, strength grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: 98.4, 93 (80-99), 114/83 (97-137/57-93), 15, 99%RA
I/O: 8h: ___ 24h: 1340/5250
Wt: 66.7 kg <- 70.5 <- 70.9 <- 71.1 <-72.4 <- 73.1 <- 75.7 <-
76.4 <- 77.1
General: well-appearing man lying in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: JVD to mandible at 60 degrees, + Kussmaul sign
CV: irregularly irregular, no m/r/g appreciated, S3 present
Lungs: fine bibasilar crackles present, no wheezing appreciated
Abdomen: soft, NT, ND, +BS
Extr: no c/c/e, 2+ DP pulses bilaterally, missing portion of
left thumb, trace pitting edema in ___
Neuro: A&Ox3, strength grossly intact
Pertinent Results:
ADMISSION LABS:
___ 10:15AM WBC-4.8 RBC-4.75 HGB-14.1 HCT-44.8 MCV-94
MCH-29.7 MCHC-31.5* RDW-15.7* RDWSD-54.2*
___ 10:15AM GLUCOSE-92 UREA N-21* CREAT-1.3* SODIUM-140
POTASSIUM-5.6* CHLORIDE-104 TOTAL CO2-21* ANION GAP-21*
___ 10:15AM CALCIUM-9.7 PHOSPHATE-4.3 MAGNESIUM-2.0
___ 10:15AM cTropnT-0.05*
___ 10:15AM CK-MB-7 proBNP-6985*
___ 10:15AM CK(CPK)-147
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-4.2 RBC-5.00 Hgb-14.7 Hct-45.7 MCV-91
MCH-29.4 MCHC-32.2 RDW-15.0 RDWSD-50.3* Plt ___
___ 05:30AM BLOOD Glucose-94 UreaN-25* Creat-1.0 Na-141
K-3.9 Cl-99 HCO3-30 AnGap-16
___ 05:30AM BLOOD Calcium-9.4 Phos-5.0* Mg-1.8
___ 05:30AM BLOOD ALT-33 AST-36 CK(CPK)-66 AlkPhos-245*
TotBili-0.9
OTHER LABS:
___ 03:48AM BLOOD calTIBC-399 Ferritn-117 TRF-307
___ 05:40AM BLOOD b2micro-2.3*
___ 03:25PM BLOOD IgG-1403 IgA-321 IgM-85
___ 03:25PM BLOOD FreeKap-26.7* ___ Fr K/L-1.51
___ 03:30PM BLOOD PEP-NO SPECIFI
___ 09:20PM URINE U-PEP-NO PROTEIN
MICROBIOLOGY:
none
PATHOLOGY:
Right ventricular endomyocardial biopsy ___:
- AMYLOID HEART DISEASE.
- The extensive amyloid deposits are highlighted by a Trichrome
stain.
IMAGING/STUDIES:
L UE/neck u/s ___:
No evidence of deep vein thrombosis in the left upper extremity.
Left subclavian vein is widely patent.
RHC/LHC cath ___:
LAD 50% mid stenosis
Circumflex has 70% stenosis, OM1 80% stenosis at level of a
bifurcation
RCA is dominant with 80% stenosis in proximal portion
Elevated right and left heart filling pressures:
RA mean 14, RV 56/18, PCW mean 32, PA: 56/28, LV 117/29, Cardiac
index: 2.19, cardiac output 3.95
Moderate pulmonary artery systolic hypertension
Biopsies taken, see pathology above
Cardiac MRI ___:
Impression: Mild concentric LVH with severely increased overall
mass index, borderline increased end diastolic volume index, and
severely depressed global left ventricular systolic function.
Moderately depressed global right ventricular systolic function.
The suboptimal myocardial nulling and diffuse late gadolinium
enhancement of the left ventricle may be seen in amyloid
cardiomyopathy. Mild mitral regurgitation. Adrenal nodule for
which dedicated imaging could be considered.
Extracardiac findings:
Incidentally noted is a bovine arch. There are moderate
bilateral pleural effusions, slightly larger on the right than
the left. There is trace perihepatic ascites. There is a 9 mm
T2 dark round lesion in the right adrenal gland (1702, 14),
which is incompletely evaluated, though statistically a benign
lesion such as an adenoma or myelolipoma.
TEE report ___:
IMPRESSION: Probable ___ thrombus. Moderate to severe ___
spontaneous echo contrast. Severely depressed left ventricular
systolic function. Mild mitral regurgitation.
Abdominal u/s ___:
IMPRESSION:
1. Hyperdynamic waveforms noted in the hepatic veins in the main
portal vein suggesting heart failure.
2. Unremarkable appearance of the liver and bile ducts.
3. Large pleural effusions are present. A scant trace of
ascites is noted in the abdomen.
TTE: ___:
The left atrial volume index is severely increased. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is at least 15 mmHg. There is
moderate symmetric left ventricular hypertrophy with normal
cavity size and severe global left ventricular hypokinesis (LVEF
= ___. Systolic function of apical segments is relatively
preserved. The estimated cardiac index is depressed
(<2.0L/min/m2). Right ventricular chamber size is normal with
severe global free wall hypokinesis. The ascending aorta is
mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a very small
circumferential pericardial effusion. There are prominent
bilateral pleural effusions.
CXR ___:
Cardiomegaly, small bilateral pleural effusions, mild pulmonary
edema.
ECG: In ER ___: a-fib, rate 129, low voltage
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Enoxaparin Sodium 80 mg SC BID atrial fibrillation bridging
to warfarin
take twice a day until directed otherwise by ___
clinic
RX *enoxaparin 80 mg/0.8 mL 80 mg SC twice a day Disp #*28
Syringe Refills:*0
5. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Warfarin 5 mg PO DAILY16 atrial fibrillation
take this dose until directed otherwise by the ___
clinic
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cardiac amyloidosis
Atrial fibrillation
Left atrial appendage thrombus
Heart failure with reduced ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with? chf // eval for sob
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. Cardiomegaly is moderate with
hilar congestion and mild pulmonary edema. There are small bilateral pleural
effusions noted. No pneumothorax. No definite signs of pneumonia though
difficult to exclude a subtle lower lobe consolidation. The mediastinal
contour is normal. Bony structures are intact. No free air below the right
hemidiaphragm.
IMPRESSION:
Cardiomegaly, small bilateral pleural effusions, mild pulmonary edema.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with decompensated systolic heart failure in the
setting of ?infiltrative cardiomyopathy. // ?infiltrative process
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. There is scant trace of
ascites in the abdomen. Large bilateral pleural effusions are noted.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The head, body and tail of the pancreas are within normal limits,
without masses or pancreatic ductal dilatation.
SPLEEN: Normal echogenicity, measuring 9.6 cm. A tiny granuloma measuring 4
mm is incidentally noted in the spleen.
KIDNEYS: The right kidney measures 10.8 cm. The left kidney measures 10.4 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones, or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
DOPPLER EXAMINATION: The main portal vein is patent with hepatopetal flow.
Undulating waveforms noted within the main portal vein. The hepatic veins are
patent and demonstrate hyperdynamic waveforms.
IMPRESSION:
1. Hyperdynamic waveforms noted in the hepatic veins a in the main portal vein
suggesting heart failure.
2. Unremarkable appearance of the liver and bile ducts.
3. Large pleural effusions are present. A scant trace of ascites is noted in
the abdomen.
Radiology Report
INDICATION: Decompensated heart failure in the setting of atrial fibrillation
with RVR. Evaluate for infiltrative process.
TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology.
IMPRESSION:
Please note that this report only contains extracardiac findings.
Incidentally noted is a bovine arch. There are moderate bilateral pleural
effusions, slightly larger on the right than the left. There is trace
perihepatic ascites. There is a 9 mm T2 dark round lesion in the right
adrenal gland (1702, 14), which is incompletely evaluated, though
statistically a benign lesion such as an adenoma or myelolipoma.
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports.
RECOMMENDATION(S): If indicated, the adrenal nodule could be further
evaluated with dedicated imaging.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ year old man with new sCHF likely ___ infiltrative
cardiomyopathy, s/p cardiac catheterization today with myocardial biopsy,
concern for possible L subclavian stenosis // ?L subclavian stenosis
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The left internal jugular and axillary veins are patent and compressible with
transducer pressure.
The left brachial, basilic, and cephalic veins are patent, compressible with
transducer pressure and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity. Left
subclavian vein is widely patent.
RECOMMENDATION(S): If there is concern for arterial stenosis, a separate
dedicated ultrasound could be obtained to evaluate the subclavian artery.
NOTIFICATION: Findings and recommendation were telephoned to Dr. ___
___ by ___ on ___ at 10:40am.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Dyspnea on exertion
Diagnosed with ATRIAL FIBRILLATION, CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.1
heartrate: 115.0
resprate: 18.0
o2sat: 100.0
sbp: 145.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | A/P: ___ with no recent PMH, referred by PCP for management of
CHF and A-fib with RVR after pt stopped outpatient therapy.
Volume overloaded on exam, EF ___, severe LVH, low E'.
Concern for infiltrative cardiomyopathy.
#Dyspnea on exertion/CHF/Cardiac amyloidosis: The patient's
findings are most consistent with congestive heart failure. On
admission, the patient had crackles, pitting edema, elevated
JVD, positive Kussmaul sign, and S3 on exam. A chest xray showed
mild pulmonary edema. ProBNP 4281. The patient had no chest pain
to suggest an acute etiology, and EKG and troponins did not
suggest ACS. A TTE on ___ showed an EF ___, severe LVH,
low E', with findings suspicious for infiltrative
cardiomyopathy. Our heme-onc team was consulted, and serum and
urine labs for infiltrative disease (SPEP, UPEP, uric acid, LDH,
wuantitative immunoglobulins, iron studies, beta 2
microglobulin) were unremarkable. A cardiac MRI was done ___
that showed nulling consistent with amyloid deposition. A right
heart cath/left heart cath was done with biopsies ___.
Biopsies were positive for amyloid deposition. Samples were sent
to an outside lab for mass spec typing. In addition, the right
heart cath/left heart cath showed 2 vessel disease, elevated RH
and LH filling pressures, and elevated PASP. No intervention was
done for the coronary disease. With regards to treatment of the
patient's CHF, he was aggressively diuresed and discharged on PO
lasix 20mg. We also started aspirin and high-intensity
atorvastatin for his newly-diagnosed CAD. Metoprolol started at
his recent outpatient visit was continued. His blood pressure
was controlled with lisinopil 2.5mg, and he was discharged on
the same medication. The patient's symptoms improved
dramatically and he was ready for discharge on ___. A
follow-up appointment was made in the heart failure clinic. We
are awaiting the results of his amyloid typing.
#Afib with RVR: diagnosed at recent outpatient appointment, had
on admission in the setting of not tolerating metoprolol
prescribed by PCP. The patient's RVR was initially controlled in
the ED with diltiazem. During the admission his rate was
controlled with metoprolol, with a goal rate in the 80___s-90's.
We did not want the rate to be slower because of the patient's
infiltrative cardiomyopathy. A TTE with cardioversion was
planned. On ___, the TTE showed clot in left atrial
appendage, so no cardioversion was performed. The patient's
CHADS2 score is 3 (CHF, HTN, DM). The patient was anticoagulated
with a heparin drip as an inpatient, and he was switched to
warfarin with a lovenox bridge prior to discharge. The patient
was discharged with lovenox training and a follow-up appointment
in the ___ clinic for warfain management.
#DM: This is a new diagnosis for the patient, with A1C 6.8% at
recent PCP ___. We controlled his glucose with diet only and
his fingersticks were well-controlled. The patient was seen by a
dietician during this admission.
#Creatinine elevation on admission: The patient's creatinine was
1.3 on admission. The patient's baseline is unknown. The
etiology of this presumed bump was unclear. Chemistries were
trended and Cr quickly dropped to 0.9, and was stable at
0.9-1.0.
# Transaminitis: The patinet had a mild transaminitis on
admission. The etiolog was unclear. A RUQ ultrasound on ___
showed unremarkable liver and bile ducts. On repeat labs the
transaminases improved slightly, but alk phos remained elevated
at 245.
***Transitional Issues***
[ ] Dry weight 66.7 kg
[ ] Continued monitoring of INR and warfarin dose (started
___
[ ] follow-up final tissue biopsy for specific amyloid type,
refer to specialist as appropriate
[ ] continued management of diuretics, monitor electrolyte
levels.
[ ] will need stress test as outpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___ Right Craniotomy for evacuation of Subdural Hematoma
___ Right Craniotomy for re-evacuation of Subdural Hematoma
History of Present Illness:
___ M s/p fall 2 days ago, found unresponsive. CTH with 1.2cm
right frontoparietal aSDH, 9mm MLS. EtOH 303. Confused,
intoxicated, but full strength.
Past Medical History:
ETOH abuse
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION ON DISCHARGE:
A&Ox3. No drift. PERRL. FC, MAE ___. requires some assistance
with ambulation through walker or assistance from another person
as contact guard.
Pertinent Results:
CXR ___:
No acute cardiopulmonary process
CT C-Spine ___:
Degenerate changes without evidence of acute fracture
CT Head ___:
1. Slight increase in right subdural hematoma with stable 9 mm
of midline
shift. No sign of downward herniation.
2. Small amount of subarachnoid blood in the right sylvian
fissure
CT Torso ___:
1. No intra-abdominal or intrathoracic solid organ injury.
2. Minimally displaced fractures of the posterior left ___ and
12th ribs.
3. Fatty liver.
4. Mildly dilated right ureter, perhaps due to reflux, although
non-specific in nature.
5. Cholelithiasis without cholecystitis
CXR ___:
The heart size, mediastinal and hilar contours are normal.
Lungs
and pleural surfaces are clear. The eleventh and twelfth ribs
are only
partially imaged on this radiograph, and known fractures in
these regions are seen to better detail on recent CT of one day
earlier.
CT head ___ Post-op:
1. Slightly decreased right convexity subdural hematoma s/p
craniotomy.
Slightly decreased associated mass effect.
2. Nondisplaced right parietal bone fracture extending into the
squamous
temporal bone, without petrous involvement.
CT Head ___:
Increasing size of right frontoparietal subdural hematoma with
increased mass effect resulting in increased subfalcine
herniation and concern for downward transtentorial herniation.
Chest X-Ray ___:
ET tube is in standard position. Cardiac size is normal. The
lungs are
clear. There is no pneumothorax or pleural effusion. The
appearance of the mediastinum is unchanged.
CT Head ___:
Interval placement of a right-sided drain status post evacuation
of subdural contents with overall decreasing shift of the
midline structures.
Chest X-Ray ___:
NG tube tip is out of view below the diaphragm, the side port is
in the
stomach. Cardiomediastinal contours are normal. ET tube is in
standard
position. The lungs are clear.
Chext X-Ray ___:
Endotracheal tube has been advanced approximately 1-1.5 cm and
now terminates approximately 2.4 cm above the level of the
carina.
CT Head ___:
Interval increase of the right subdural hematoma with more blood
identified along the anterior and posterior convexity. There is
increase in associated mass effect and compression of the
ventricles.
CT Head ___:
No significant change in right subdural hematoma, mass effect or
leftward
shift of midline structures since ___. External
drain in
appropriate and stable position
CT Head ___:
No significant change in postoperative appearance of right
subdural hematoma and degree of local mass effect and subfalcine
herniation
LENIS ___:
No evidence of DVT in the right or left lower extremity
CXR ___:
Overall, there has been little change in the appearance of the
chest since the recent study except for development of subtle
patchy and
linear opacities at the left lung base, which could be due to
atelectasis,
aspiration, or early pneumonia. Followup radiographs may be
helpful in this regard.
CT Head ___:
Interval removal of right frontal approach drain with slight
increase in pneumocephalus overlying the right frontal
convexity. No other significant change in the appearance of
right subdural hematoma and degree of local mass effect.
CXR ___:
Interval re-positioning of a feeding tube, which now terminates
in
the proximal stomach but the proximal portion of the tip is just
above the GE junction level. Nasogastric tube terminates in the
region of the pylorus. Endotracheal tube is in standard
position. Cardiomediastinal contours are normal, and imaged
portions of the lungs are clear (small portion of right lung
laterally has been excluded).
Medications on Admission:
seroquel,? depakote
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q8H:PRN PAIN
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. CloniDINE 0.1 mg PO TID:PRN hypertension
4. Docusate Sodium (Liquid) 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. LeVETiracetam 500 mg PO BID
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
8. Multivitamins 5 mL PO DAILY
9. Ondansetron 4 mg IV Q8H:PRN nausea; vomiting
10. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
11. Senna 1 TAB PO BID:PRN Constipation
12. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural Hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Found down.
COMPARISON: None.
TECHNIQUE: Single portable view of the chest.
FINDINGS: The lungs are clear. Cardiac silhouette is normal in size. There
is no pleural effusion, pneumothorax or pulmonary edema.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Found down with subdural hematoma seen on outside hospital study.
COMPARISON: Outside hospital head CT ___.
TECHNIQUE: Axial MDCT images were obtained through the brain without the
administration of IV contrast. Coronal and sagittal reformats were also
examined.
FINDINGS: Again seen is a right cerebral convexity subdural hematoma with a
maximum depth of 13.8 mm from the inner table, increased by 1 mm compared to
the prior study. There is 9 mm of midline shift. There is also a small
amount of subarachnoid blood in the right sylvian fissure. The basal cisterns
remain patent. An old left frontal infarct is noted.
There is a fracture of the right temporal bone without involvement of the
skull base. No other fractures are identified. A right frontal subgaleal
hematoma is also present. Deformity of the right zygomatic arch is noted,
likely chronic. There is mucosal thickening in the maxillary sinuses and
bilateral ethmoid air cells.
IMPRESSION:
1. Slight increase in right subdural hematoma with stable 9 mm of midline
shift. No sign of downward herniation.
2. Small amount of subarachnoid blood in the right sylvian fissure.
Radiology Report
HISTORY: Trauma. Found down.
COMPARISON: Outside hospital CT from 1 earlier.
TECHNIQUE: MDCT of the cervical spine without contrast with axial, coronal and
sagittal reformations.
FINDINGS: Multilevel multifactorial degenerative changes are noted with
anterior and posterior osteophyte formation, the worst at the C5-C6 level. At
this level there is minimal canal narrowing from a posterior disc osteophyte
complex. There is no evidence of fracture. There is minimal loss of lordosis
is likely due to degenerative changes. The dens is intact. There is no
prevertebral soft tissue swelling
The lung apices demonstrate emphysematous changes with scarring and blebs.
Mucosal sinus thickening is noted bilaterally.
IMPRESSION: Degenerate changes without evidence of acute fracture.
Radiology Report
HISTORY: Found down. Trauma.
TECHNIQUE: CT of the chest, abdomen and pelvis with IV contrast. Coronal and
sagittal reformations were reviewed. Oral contrast was not administered.
COMPARISON: None
FINDINGS:
LOWER CHEST: There is no mediastinal hilar or axillary lymphadenopathy by CT
criteria. The aorta and great vessels unremarkable. There is no mediastinal
hematoma. The heart is of normal size. The lungs are clear.
ABDOMEN: The liver is diffusely hypodense. There are no focal liver lesions.
The main portal vein is patent.
The gallbladder contains numerous stones but no evidence of cholecystitis.
The spleen, pancreas and bilateral adrenal glands are normal.
Bilateral kidneys enhance and excrete contrast symmetrically without evidence
of hydronephrosis or suspicious renal masses. The right kidney is chronically
scared with loss of cortex in a focal segment of the upper pole. On the right
there is a mildly dilated ureter throughout its course without an obvious
obstruction such as stone or mass.
The abdominal aorta is normal in course and caliber.
There is no abdominal free fluid or lymphadenopathy.
The stomach, small, and large bowel are normal in course and caliber.
Appendix is normal.
PELVIS: The bladder is distended. The prostate, and rectum are unremarkable.
There is no pelvic free fluid or lymphadenopathy. A penile prosthesis is
noted.
BONES: There are acute appearing minimally displaced fractures of the
posterior left 12th rib and the posterior lateral left 11th rib. The lateral
left 10th rib is slightly deformed, likely due an an old injury.
IMPRESSION:
1. No intra-abdominal or intrathoracic solid organ injury.
2. Minimally displaced fractures of the posterior left ___ and 12th ribs.
3. Fatty liver.
4. Mildly dilated right ureter, perhaps due to reflux, although non-specific
in nature.
5. Cholelithiasis without cholecystitis
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: The heart size, mediastinal and hilar contours are normal. Lungs
and pleural surfaces are clear. The eleventh and twelfth ribs are only
partially imaged on this radiograph, and known fractures in these regions are
seen to better detail on recent CT of one day earlier.
Radiology Report
INDICATION: ___ male with history of right frontal subdural hematoma
status post evacuation. Assess for postoperative hemorrhage.
COMPARISON: Preoperative non-contrast head CTs from ___
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast. Bone and soft tissue algorithms were reviewed. Coronal and
sagittal reformations were prepared.
NON-CONTRAST HEAD CT: The patient is status post right craniotomy. Right
convexity subdural hematoma remains present, but slightly decreased in size.
Right extraaxial pneumocephalus is now present. There is decreased leftward
shift of midline structures and decreased right subfalcine herniation. There
is no uncal herniation or compression of basal cisterns. Subarachnoid blood
within the right sylvian fissure has decreased in density. The right lateral
and third ventricles remain compressed, and the left lateral ventricle remains
mildly dilated. A chronic left frontal white matter infarct with
periventricular as well as subcortical involvement is again seen.
Again seen is a nondisplaced right parietal bone fracture posterior to the
craniotomy, extending into the squamous portion of the temporal bone. Right
mastoid is underpneumatized, likely from prior chronic infections, but the
pneumatized bilateral mastoid air cells are well aerated. Mucosal thickening
is seen within the ethmoid air cells, inferior frontal sinuses, and imaged
portions of the maxillary sinuses. A right zygomatic arch fracture is
partially visualized, thought to be chronic on prior studies on which it was
better assessed.
IMPRESSION:
1. Slightly decreased right convexity subdural hematoma s/p craniotomy.
Slightly decreased associated mass effect.
2. Nondisplaced right parietal bone fracture extending into the squamous
temporal bone, without petrous involvement.
Radiology Report
HISTORY: ___ man status post right subdural hematoma evacuation,
evaluate for interval change.
TECHNIQUE: Contiguous axial MDCT images of the brain were obtained without
the administration of IV contrast.
CTDIvol: 70.73 mGy.
DLP: 1202 mGy-cm.
COMPARISON: Non-enhanced CT of the head from ___.
FINDINGS:
Comparison to the most recent prior CT is limited by differences in the tilt
of the patient's head. The patient is status post right craniotomy. There has
been interval enlargement of the right subdural hematoma, with increase in
leftward shift of midline structures and subfalcine herniation compared to
approximately 15 hours earlier. Right lateral and third ventricles remain
effaced. There is interim enlargement of the atrium and occipital horn of the
left lateral ventricle, indicating entrapment, with new surrounding
hypodensity indicating subependymal CSF migration. Though there is new mild
distortion of the midbrain due to increased shift of midline structures, there
is no uncal herniation and no compression of basal cisterns. There has been
interval decrease in pneumocephalus. Small subarachnoid blood in the right
sylvian fissure is stable. A left frontal chronic white matter infarct is
again seen.
A nondisplaced right parietal bone fracture is again noted posterior to the
craniotomy, extending into the squamous portion of the temporal bone. A
chronic right zygomatic arch fracture is also seen. Mild mucosal thickening
is again seen in the ethmoid air cells.
IMPRESSION:
Interval increase in right subdural hematoma with increased leftward shift of
midline structures and subfalcine herniation.
Findings were discussed with ___ by Dr. ___ telephone at
10:45 AM on ___.
Radiology Report
HISTORY: ___ alcoholic male found down with right subdural hematoma
and right subarachnoid hemorrhage. Patient is status post evacuation and is
now presenting with change in mental status. Assess for interval change.
COMPARISON: Non-contrast head CTs dating back to ___, most
recent from ___, at 8:57 a.m.
TECHNIQUE: MDCT axial images of the brain were obtained without intravenous
contrast. Bone and soft tissue algorithms were reviewed. Coronal and
sagittal reformations were prepared.
NON-CONTRAST HEAD CT: The patient is status post evacuation of a right
subdural hematoma with expected postoperative changes. However, there has
been interval increase in the size of the right frontal component measuring up
to 17 mm (2a:18). Additionally, there is increased mass effect upon the right
cerebral hemisphere with increased shift of the usually midline structures to
the left, now measuring 13 mm as compared to 9 mm on most recent prior
examination from the same day. Additionally, there is increased effacement of
the suprasellar cistern with concern for downward transtentorial herniation.
Dilatation of the occipital horn of the left lateral ventricle with evidence
of transependymal CSF flow is similar to prior and consistent with entrapment.
A previusly seen small amount of subarachnoid hemorrhage within the right
sylvian fissure is not clearly evident on the current examination. No new
left-sided hemorrhage is identified. A nondisplaced right temporal bone
fracture is similar to prior. Mucosal thickening is seen within the ethmoid
air cells. The mastoid air cells remain well aerated.
IMPRESSION: Increasing size of right frontoparietal subdural hematoma with
increased mass effect resulting in increased subfalcine herniation and concern
for downward transtentorial herniation.
Dr. ___ communicated the above results to Dr. ___ at
6:41 p.m. on ___, immediately after discovery. Findings were
known to the surgical team and patient was being sent emergently to the
operating room for decompression.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess ET tube.
ET tube is in standard position. Cardiac size is normal. The lungs are
clear. There is no pneumothorax or pleural effusion. The appearance of the
mediastinum is unchanged.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess NG tube.
NG tube tip is out of view below the diaphragm, the side port is in the
stomach. Cardiomediastinal contours are normal. ET tube is in standard
position. The lungs are clear.
Radiology Report
HISTORY: Re-evacuation of right subdural hematoma. Question interval change.
COMPARISON: ___.
TECHNIQUE: Non-contrast head CT.
FINDINGS: In the interval since the prior study, there is now a drain in
place within the right subdural collection of hemorrhage and air. The
resultant shift of the midline structures has decreased, now at approximately
6 mm. Effacement of the right-sided sulci as well as the right lateral
ventricle still remains. The basal cisterns are patent. No new hemorrhage is
identified and there is no evidence of cytotoxic or vasogenic edema.
IMPRESSION: Interval placement of a right-sided drain status post evacuation
of subdural contents with overall decreasing shift of the midline structures.
Radiology Report
EXAM: Chest, single semi-upright AP portable view.
CLINICAL INFORMATION: Intracranial bleed status post right craniotomy.
___.
FINDINGS: Endotracheal tube is seen, terminating approximately 2.4 cm above
the level of the carina which has advanced approximately 1 cm since the prior
study. Enteric tube is seen coursing below the level of the diaphragm into
the left upper quadrant inferior aspect not included on the image. External
artifact projects over the right lung apex making this area difficult to
assess. Elsewhere, there is no focal consolidation. No pleural effusion or
evidence of pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION: Endotracheal tube has been advanced approximately 1-1.5 cm and
now terminates approximately 2.4 cm above the level of the carina.
Clear lungs.
Radiology Report
HISTORY: ___ man status post right craniotomy and evacuation of
subdural hematoma x2. Rule out hemorrhage. Please perform portable head CT.
TECHNIQUE: Contiguous axial MDCT images of the brain were acquired without
the administration of IV contrast.
COMPARISON: Nonenhanced CT of the head from ___.
FINDINGS:
The patient is status post right craniotomy for subdural hematoma evacuation.
There has been interval increase of the right subdural hematoma with
associated increase in mass effect and leftward shift of midline structures.
More subdural blood is seen along the anterior and posterior convexity of the
brain. There is increased mass effect causing bilateral ventricle
compression. An external subdural drain is in stable and appropriate
position.
A prior left frontal infarct is again noted. There are no new areas of
hemorrhage or infarction, and the basal cisterns are patent. The globes are
unremarkable.
IMPRESSION:
Interval increase of the right subdural hematoma with more blood identified
along the anterior and posterior convexity. There is increase in associated
mass effect and compression of the ventricles.
Radiology Report
AP CHEST, 4 A.M., ___
HISTORY: Subdural evacuation. Respiratory distress. Still intubated.
IMPRESSION: AP chest compared to ___:
ET tube and nasogastric tube in standard placements respectively. No
pneumothorax, pleural effusion or atelectasis. Lungs clear. Heart size
normal.
Radiology Report
HISTORY: ___ male, followup bleed.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast.
COMPARISON: None and CT scan from ___.
FINDINGS:
The patient is status post right craniotomy following subdural hematoma
evacuation. An external drain is in appropriate and stable position. The
right subdural hematoma persists without any significant change in size.
There continues to be effacement of the sulci and lateral ventricle. A
leftward shift of midline structures is unchanged. A prior left frontal
infarct is again noted. There are no areas of hemorrhage or infarction, and
the basal cisterns are patent. The globes are unremarkable.
IMPRESSION:
No significant change in right subdural hematoma, mass effect or leftward
shift of midline structures since ___. External drain in
appropriate and stable position.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: ___.
FINDINGS: Overall, there has been little change in the appearance of the
chest since the recent study except for development of subtle patchy and
linear opacities at the left lung base, which could be due to atelectasis,
aspiration, or early pneumonia. Followup radiographs may be helpful in this
regard.
Radiology Report
INDICATION: Right subdural hematoma, right subarachnoid hemorrhage. Evaluate
for interval change.
COMPARISON: CT head ___ and ___. Also, outside CT head
___.
TECHNIQUE: Axial MDCT images were obtained through the brain without IV
contrast. Some images were repeated due to motion artifact with improved
outcome. Coronal, sagittal and thin section bone algorithm reconstructed
images were generated.
TOTAL BODY DLP: 1665 mGy-cm.
FINDINGS: The patient is status post right craniotomy and evacuation of right
subdural hemorrhage. Post-surgical soft tissue edema of the scalp persists.
There is no significant appreciable change in size and extent of subdural
collection layering over the right cerebral convexity, with surgical drain
unchanged in position. Pneumocephalus has decreased. There is persistent
effacement of the right hemispheric sulci and gyri, with persistent effacement
of the lateral ventricles, right greater than left, with midline shift of
approximately 5 mm, stable. The prior focus of subarachnoid hemorrhage along
the sylvian fissure is no longer appreciated. Chronic left frontal lobe
subcortical infarct is redemonstrated.
The patient remains intubated. The left middle ear cavity is clear. There is
partial opacification of several left mastoid air cells. The underdeveloped
right mastoid air cells are nearly completely opacified but the right middle
ear cavity is clear. There is stable mucosal thickening and partial
opacification of the partially visualized paranasal sinuses.
IMPRESSION: No significant change in postoperative appearance of right
subdural hematoma and degree of local mass effect and subfalcine herniation.
Radiology Report
INDICATION: Subarachnoid hemorrhage, now with new fever of SQH, evaluate for
DVT.
COMPARISON: None.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound evaluation was
performed on the bilateral lower extremity veins.
FINDINGS: There is normal compressibility, flow and augmentation of the
bilateral common femoral, proximal femoral, mid femoral, distal femoral and
popliteal veins. Normal color flow is demonstrated in the posterior tibial
and peroneal veins. There is normal respiratory variation in the common
femoral veins bilaterally.
IMPRESSION: No evidence of DVT in the right or left lower extremity.
Radiology Report
INDICATION: Subdural and subarachnoid hemorrhage requiring emergent
decompression. Evaluate for acute change.
COMPARISON: Non-enhanced head CT from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axes and thin section bone algorithm reconstructed images
were acquired.
DLP: 1026 mGy-cm.
CTDI volume: 61 mGy.
FINDINGS: Compared to the prior study of ___, there has been removal
of a right frontal-approach drain. The patient is status post right
craniotomy and evacuation of right subdural hemorrhage. There is slight
interval increase in pneumocephalus. There is unchanged appearance of size
and extent of the subdural collection layering over the right cerebral
convexity. There is persistent effacement of the right hemispheric sulci and
right lateral ventricle with unchanged 5-mm leftward shift of normally midline
structures. The basal cisterns appear patent. Chronic left frontal lobe
subcortical infarct is unchanged. There is unchanged opacification of the
right underdeveloped mastoid air cells. The left mastoid air cells are clear.
Partial opacification of the bilateral ethmoid air cells and a right maxillary
mucous retention cyst are noted.
IMPRESSION: Interval removal of right frontal approach drain with slight
increase in pneumocephalus overlying the right frontal convexity. No other
significant change in the appearance of right subdural hematoma and degree of
local mass effect.
Radiology Report
SERIES OF PORTABLE CHEST RADIOGRAPHS OF ___
COMPARISON: Study of earlier the same date.
Three serial radiographs of the chest are submitted for interpretation. On
the initial radiograph, a feeding tube coils in the esophagus and is
subsequently directed cephalad with tip terminating above the thoracic inlet
level. On the second radiograph, the tube coils in the lower thoracic
esophagus with a similar cephalad course and termination above the thoracic
inlet level. On the final radiograph, there is no longer coiling of the tube,
but the tip is located at the GE junction level. At the time of this
dictation, a repeat chest radiograph has been obtained and dictated
separately, documenting advancement of this tube. With the exception of the
above described feeding tube placement and re-positioning, there has not been
a substantial change in the appearance of the chest since the previous study
of earlier the same date.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: Study of earlier the same date.
FINDINGS: Interval re-positioning of a feeding tube, which now terminates in
the proximal stomach but the proximal portion of the tip is just above the GE
junction level. Nasogastric tube terminates in the region of the pylorus.
Endotracheal tube is in standard position. Cardiomediastinal contours are
normal, and imaged portions of the lungs are clear (small portion of right
lung laterally has been excluded).
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ETOH, s/p Fall, Head injury, Transfer
Diagnosed with SUBARACHNOID HEM-NO COMA, ACCIDENT NOS
temperature: 98.6
heartrate: 72.0
resprate: 18.0
o2sat: 97.0
sbp: 133.0
dbp: 99.0
level of pain: 13
level of acuity: 2.0 | Patient presented to ___ and was admitted to the ___
care unit for close neurological monitoring and care. Plan was
made that he would undergo surgery on ___ for evacuation of
his right subdural hematoma. Initially upon admission he was
intoxicated and unable to provide informed cosnent for surgery
and a repeat CT head was stable. On ___ he was awake alert and
oriented x 3, understood his current condition, and was able to
provide informed consent for surgery. he was taken to the
oeprating for for evacuation of his right subdural hematoma via
right sided craniotomy. he toerlated the procedure well was
extubated in teh oeprating room and transferred to the ICU
post-operatively for further monitoring and care. He underwent a
post-operative CT head that showed decreased right subdural
hematoma with decrease in midline shift. He remained stable
overngiht into ___ and on mornign rounds he was noted to have
increased somnolence and difficulty with teh date. A CT scan of
the head was done which showed increased blood products and
increased midline shift. He was closely monitored following this
but given a change in neurologic status, returned to the
operating room for a re-evacuation of the subdural hematoma on
the right. He remained intubated s/p the procedure and returned
to the ICU for close monitoring.
On ___, the patient's examination waxed and waned overnight.
The subgaleal drain output was 40cc since the OR and the
Subdural drain output was 35cc since the OR. The patient was
actively withdrawing from alcohol and was requiring additional
doses of Ativan per CIWA scale.
On ___, the patient remained intubated as he was withdrawing
and requiring increased benzodiazpines. He received a
Phenobarbitol bolus for withdrawal symptoms. The subdural drain
and subgaleal drains remained in place for continued drainage.
Antibiotic coverage continued as the drains remained in place.
The non-contrast head CT shows a stable bleed with slight
improvement in midline shift and pneumocephalus.
On ___, the subgaleal drain was removed and 2 staples were
placed for closure. He continued with intermittent fevers. The
sputum gram stain showed gram positive rods; the culture remains
pending at this time. He continues to receive Phenobarbitol for
etoh withdrawal. The non-contrast head CT obtained today showed
stable post op changes and subdural drain in place with stable
fluid collection. Subgaleal drain removed, 2 staples placed at
drain site. Temp, sputum gram stain shows 1+ GPRs, pending
culture. Receiving Phenobarb bolus for etoh withdrawal.
On ___, he remained intubated and received phenobarbitol
boluses for his withdrawl. Head CT was performed and was stable.
His subdural drain was removed, two staples were placed.
On ___, a non-contrast head CT was performed and was stable. He
was extubated. His CDiff culture was positive and he was started
Flagyl 500mg PO TID.
On ___, Mr. ___ underwent a bedside speech & swallow
evaluation which he passed.
On ___, the patient was neurologically and hemodynamically
intact and was stable for floor transfer, but due to his
Phenobarbital taper he remained in the ICU for close monitoring.
___, the patient remained neurologically and hemodynamically
stable and was trasfered to the floor in stable condition. His
staples were removed, incision healing well.
On ___ he was walking with ___ and did well. later in the day he
fell OOB, did not strike head and did not require imaging or
workup. He was awaiting placement. Later int eh evenign he
reported difficulty urinating with a burning sensation. A UA was
sent which was not overtly concerning for UTI. HE remaiend
stable into ___. He was screened and accepted to the ___
for rehab. Plans were made for discharge, he was given
instructions for followup, and all questions were answered. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Vicodin / Penicillins / Aspirin
Attending: ___
Chief Complaint:
dyspnea
lower extremity pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with HTN, dCHF (EF >55% ___, recurrent MRSA
infections, TURP, CKD stage 3 (baseline 1.5-1.7), h/o L leg
split-thickness skin graft and chronic LLE lymphedema and pannus
edema who presents to emergency Department with SOB and ___
ulcer. Patient states that on ___ he developed an
allergic reaction with severe swelling and hives and shortness
of breath. He decided to go off his medications for this
allergic reaction and since then he is not taking any of his
medications. He since has also stopped taking his oxygen at home
because he felt like he had an allertic reaction to it. He is
coming in to the emergency room today because he felt like he
had difficulty ambulating in the setting worsening left ankle
pain as well as increased shortness of breath. He has not been
able to take any of his Medication for fear of an allergic
reaction.
In the ED, initial vitals were: 99.5 88 135/43 26 88% RA
- Labs were significant for H&H ___, WBC of 8.4, Chem 7
significant for BUN/Cr of ___. Tnt <0.01, BNP of 1243, UA
without infection.
- Imaging w/ chest xray showed Cardiomegaly with pulmonary
vascular congestion.
- The patient was given 80 IV lasix, 25 mg of Carvedilol, 800 mg
of Ibuprofen, and Tylenol.
Vitals prior to transfer were:
Upon arrival to the floor, pt states he is not far from
baseline. He speaks in full sentences but states he has had to
sleep upright for the last two weeks (coinsides with stopping
all medications). He denies cough, chest pain, fevers/chills. He
states ___ edema and chronic venous stasis is at baseline. No
changes in pannus.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
PAST MEDICAL HISTORY:
0. dCHF (EF >55% ___
1. Recurrent MRSA infections.
2. Lower extremity lymphedema.
3. Asthma.
4. Gout.
5. Hypertension.
6. Morbid obesity.
7. Bilateral inguinal hernia repairs presumably with mesh ___
at ___.
8. Left leg injury and subsequent surgery including a
split-thickness skin graft.
9. TURP.
10. Sleep apnea.
11. Thyroid nodule.
Social History:
___
Family History:
+ for CAD, DM and alcoholism
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: HR 71 91RA 98.6 126/48
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRL
Neck: Supple, unable to determine JVP due to neck size
CV: S3, soft systolic ejection murmur at the upper left sternal
border with radiation to the upper right sternal border, and a
very soft apical holosystolic murmur that radiates to the left
axilla
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Obese, no rebound or guarding, large, woody panus
formation
GU: No foley
Ext: Chronic venous stasis and lymphedema, 2+ nonpitting edema.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
PHYSICAL EXAM ON DISCHARGE:
VS: T 97.9 BP 103-134/63-77 HR ___ R 18 SpO2 95-98% ___
Wgt: 154kg
TELE: SR ___, satting 92-97%2L desat to 82% overnight
GENERAL: Morbidly obese, On O2NC in NAD. Mood, affect
appropriate
HEENT: PERRL, EOMI, moist mucous membranes
NECK: Unable to determine JVP due to body habitus
CV: S3, soft systolic ejection murmur at the LUSB with radiation
to the RUSB, and a soft apical crescendo-decrescendo murmur that
radiates to the left axilla
Lungs: CTAB, no crackles, rales, rhonchi
Abdomen: Morbidly obese, large, woody panus formation
Ext: Chronic venous stasis and lymphedema bilaterally with 1+
edema to thighs, dry ulcer on posterior left heel and medial L
lower calf which is dry
Pertinent Results:
ADMIT LABS:
___ WBC-8.4 RBC-3.52* Hgb-10.8* Hct-32.4* MCV-92 MCH-30.7
MCHC-33.3 RDW-13.2 RDWSD-43.5 Plt ___
___ ___ PTT-32.0 ___
___ Glucose-118* UreaN-21* Creat-1.4* Na-136 K-3.9 Cl-96
HCO3-31 AnGap-13
___ proBNP-1243*
___ cTropnT-<0.01
___ Calcium-8.8 Phos-3.2 Mg-2.1 UricAcd-11.8*
___ FreeKap-46.4* FreeLam-44.2* Fr K/L-1.05
CXR ___:
Cardiomegaly with pulmonary vascular congestion.
CXR ___
Since ___, cardiomegaly is accompanied by
worsening pulmonary vascular congestion and mild interstitial
edema. No definite areas of consolidation to suggest a site of
infectious pneumonia.
CXR ___:
Mild pulmonary edema, mild cardiomegaly.
___ TTE
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. There is severe symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are moderately thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Severe symmetric LVH with a small LV cavity and
hyperdynamic systolic function. At least mild aortic stenosis
(may be underestimated).
___ Renal U/S
IMPRESSION:
1. No evidence of hydronephrosis, stones or obstruction.
2. Collapsed urinary bladder, though visualization limited
secondary to body habitus.
MICRO:
Blood cultures ___ and ___ - final no growth
Urine culture ___ >3colonies consistent with skin flora
Throat culture HSV - No HSV - final
Sputum culture ___ - final, commensal respiratory flora
OTHER PERTINENT LABS: see below
HA1c: ___
FreeKap 46.4, FreeLam 44.2, Fr K/L 1.05
UA unremarkable
DISCHARGE LABS:
___ WBC-8.8 RBC-3.94* Hgb-11.7* Hct-37.6* MCV-95 MCH-29.7
MCHC-31.1* RDW-13.0 RDWSD-45.1 Plt ___
___ Glucose-106* UreaN-56* Creat-1.8* Na-138 K-3.8 Cl-89*
HCO3-37* AnGap-16
___ Calcium-10.0 Phos-4.2 Mg-2.2
___ METHYLMALONIC ACID- *PENDING*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO QAM
2. Carvedilol 25 mg PO BID
3. Amlodipine 5 mg PO DAILY
4. Furosemide 80 mg PO DAILY
5. Ibuprofen 800 mg PO Q8H:PRN pain
6. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Acetaminophen 650 mg PO Q4H:PRN pain
take one every 6 hours as needed for pain
3. Allopurinol ___ mg PO EVERY OTHER DAY
take this medication every day to prevent gout flairs
4. Amlodipine 10 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
take 2 puffs as needed for shortness of breath
6. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
Take as needed for muscle spasm
7. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
take daily as needed for back pain
8. Torsemide 40 mg PO DAILY
Take daily for heart failure
9. Fexofenadine 60 mg PO BID pruritis
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Diastolic heart failure exacerbation
Acute on chronic kidney disease
SECONDARY DIAGNOSIS:
Moderate Aortic Stenosis
Hypertensive Urgency
Bronchitis
Gout flare
Contact Dermatitis
Adjustment reaction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hypoxia
COMPARISON: ___ and ___.
FINDINGS:
AP portable upright view of the chest. The heart is mildly enlarged and
there is hilar engorgement compatible with pulmonary vascular congestion.
There is no frank pulmonary edema, effusion or pneumothorax. No convincing
signs of pneumonia. Bony structures are intact.
IMPRESSION:
Cardiomegaly with pulmonary vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with fever and CHF // r/o pneumonia
IMPRESSION:
Since ___, cardiomegaly is accompanied by worsening pulmonary
vascular congestion and mild interstitial edema. No definite areas of
consolidation to suggest a site of infectious pneumonia.
Radiology Report
INDICATION: ___ year old man with cough and increased sputum // r/o pna
TECHNIQUE: Chest PA and lateral
FINDINGS:
Compared to ___, pulmonary vascular congestion has slightly
worsened. No acute focal consolidation. No pleural effusions.Mild
cardiomegaly.
IMPRESSION:
Mild pulmonary edema, mild cardiomegaly.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with heart failure now s/p diuresis, CKD and
persistent ___ and uremia // Obstruction?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 13.4 cm. The left kidney measures 11.5 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The urinary bladder is poorly visualized, given the patient's body habitus,
though appears collapsed.
IMPRESSION:
1. No evidence of hydronephrosis, stones or obstruction.
2. Collapsed urinary bladder, though visualization limited secondary to body
habitus.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoxia, Leg pain
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPOXEMIA
temperature: 99.5
heartrate: 88.0
resprate: 26.0
o2sat: 88.0
sbp: 135.0
dbp: 43.0
level of pain: 0
level of acuity: 1.0 | ___ yo male with HTN, dCHF (EF >55% ___, recurrent MRSA
infections, TURP, CKD stage 3, h/o L leg split-thickness skin
graft and chronic LLE lymphedema and pannus edema who presents
with heart failure exacerbation in the setting of medication
nonadherence and increased LLE pain consistent with gout flare.
# dCHF exacerbation
Presenting with orthopnea in the setting of medication
nonadherence, BNP 1243 and CXR with pulmonary edema indicating
CHF exacerbation. No pulmonary infiltrate to suggest PNA and no
increased cough to suggest Asthma/COPD exacerbation on admit.
Ruled out amyloidosis as FreeKap 46.4, FreeLam 44.2, Fr K/L
1.05. HA1c 5.9%. Diuresed with goal net negative ___ L daily.
Home Torsemide 80 daily. Received multiple IV boluses for 100mg
lasix followed by several days of a 10cc/hr Lasix drip with
significant UOP. Held two days in the setting ___ on CKD.
Switched ___ to Torsemide 40 daily with new even UOP/weight. On
home O2 of ___. In terms of optimizing antihypertensives, we
would prefer that he take carvedilol to improve cardiac
function, but Mr. ___ believes that he is allergic so is
refusing to take carvedilol. Consider further discussion
outpatient. BPs have been stable on maximum amlodipine 10mg
daily. Discharged on 40mg torsemide PO daily.
# ___ on CKD stage 3: Baseline 1.5-1.7. Creatinine 1.4 on admit
> up to 2.5 ___ > down to 1.8 ___. ___ likely secondary to
overdiuresis given FeUrea 20; unremarkable renal ultrasound, and
higher dose of losartan. Improved with holding PO Torsemide and
losartan (and with avoiding the significant amounts of ibuprofen
that patient takes at home). Restarted torsemide ___ with
continued improvement in creatinine down to 1.8.
# Leg and back pain
H/o of gout; likely also with radiculopathy and msk pain.
Completed a course of steroids for his gout without significant
improvement in pain, though also on Lasix drip which will
exacerbate gout further. States that ibuprofen is the only thing
that cures his pain; however, given his cardiac and renal
function, he should not be on NSAIDs, which has been discussed
with the patient at length. Encouraged to participate in
Physical therapy as this would help improve radiculopathy or
arthritis. Started on gabapentin and lidocaine patch. Started on
1gm acetaminophen PO q6hours with significant improvement in
pain. Also attributes improvement to cyclobenzaprine. Will
switch to acetaminophen to 650 q6hrs prn outpatient. Will
continue cyclobenzaprine and lidocaine patch PRN for pain. B12
WNL; waiting for Methylmalonic acid lab for neuropathy workup.
Consider further workup outpatient.
# Gout
acute gout flare in the setting of diuresis; currently in a
hyperuremic state (Uric acid level 11.8). Pt takes 800 mg of
ibuprofen TID at home; advised to stop dt CAD and CKD. Pt states
they have confirmed gout by arthrocentesis, but no results in
OMR. Appreciate rheum rec for methylpred taper and allopurinol.
Completed methylpred taper 60 ___ & ___ > decreased by 10mg
per day until completion on ___. Started allopurinol ___
daily ___ and will continue outpatient.
#HTN: BP to 170s on admit > well controlled on amlodipine 10mg
while inpatient. For cardiac function, would prefer that patient
is on carvedilol or losartan; however, he states that he is
allergic. Patient also refused labetolol as he only wants to be
on one antihyprtensive. While not the ideal regimen for his
heart failure, his BPs are stable on amlodipine 10mg daily.
continuing home amlodipine 10mg tablet daily.
# Adjustment reaction; Personality disorder (schitotypal vs
narcissistic); Autism spectrum disorder
Patient with concrete thinking and limited health literacy
leading to fear of medications and medical care. For example:
believes that ibuprofen and "15 cherries" will cure his gout.
Also with some paranoia about health and people coming into his
home. Appreciate psych recs to focus on immediate needs with
patient and to communicate concrete and concise informant about
treatment plan
# Leukocytosis: Leukocytosis now resolved. WBC increased in the
setting of acute gout flare. Patient believes that he is having
an allergic reaction to the medications we are giving him;
however, no signs of systemic allergic reaction on exam. In
terms of infectious workup, Blood cultures with NGTD. Started on
ceft/vanc ___ for presumed LLE cellulitis initially; however
appears more like chronic venous stasis with lymphedema and
gout, so ceft/vanc stopped ___. With some cough productive of
green/yellow phlegm ___ with sinus congestion. CXR difficult to
assess, but no clear infiltrate. Suspected bronchitis. Completed
5 day course of Azithromycin. Blood cultures with NGTD. Cough
and leukocytosis resolved on discharge.
# Rash face/chest and Aphthous oral ulcers; Patient concerned
about allergic reaction. Evaluated by dermatology and count only
to have contact dermatitis and aphthous oral ulcers. ___ seek
allergy testing outpatient. Derm recommendations below; however,
patient did not feel better with creams or ace bandage
wrappings. HSV culture preliminary negative.
- Face rash: 2.5% hydrocortisone BID PRN
- Truck rash: triamcinolone 0.1% cream BID PRN
- Pruritis: fexofenadine 60mg BID
- Lower extremities: aquafor TID > kerlex and ace bandages
- LLE ulcer eschar: collagenase and xeroform
- Aphthous ulcers: HSV culture, viscous lidocaine
- Nose irritation: nasal saline QID PRN
#Moderate Aortic Stenosis
Peak velocity 4.4, Mean gradient 45. Likely complicating HF
exacerbation. Outpatient follow up with Dr. ___.
#CAD
H/o ?NSTEMI without intervention. Continue clopidogrel 75 mg
(Asa allergy). Discussed need to avoid NSAIDs given CAD and CKD.
#Asthma/OSA
Has both restrictive and obstructive PFTs from ___. Pt has some
inspiratory or expiratory wheezes on exam after lungs cleared
from pulmonary edema, unlikely to have exacerbation though
required home albuterol at times throughout hospitalization.
Continue 2 puffs alb 4x daily PRN; continued nebs PRN.
___ Edema
chronic venous stasis and lymphedema with acute gout flare.
Treatment with Lasix as above with improvement. Derm
recommendations to treat LEs and Panus with aquafor TID > kerlex
and ace bandages, but patient felt that this increased his pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Nausea/Vomiting, Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with hx of malrotation s/p
surgery who presents with abdominal pain.
At baseline, patient reports that he has had repeated episodes
of severe nausea and vomiting, but never abdominal pain. Since
___ patient has been experiencing extreme nausea, vomiting,
and new abdominal pain, which he found concerning. He has been
seen in ED three times this week. He is unable to tolerate PO
well, but reports still having a good appetite. He reports that
he has been having waxing and waning symptoms of his GI symptoms
that ranges from hours to days. States that his symptoms are the
worst at night and in the morning. He describes his abdominal
pain as diffuse, twisting ___ pain that does not radiate.
Pt took omeprazole and Zofran ODT at home this morning pt states
he threw both of them up. Denies taking any pain medications.
Reports that he had diarrhea once this morning. Denies blood in
stool or vomit. Has been having associated chills with the
abdominal pain along with mild migraines and SOB. He does
endorse heavy marijuana use everyday, last used on ___.
Denies any relief of N/V with showering. Denies any fevers, CP,
sick contacts, recent travel, or new ingestions.
Patient has hx of malrotation of gut s/p surgery in ___.
Reports having had a gastric emptying study that revealed slow
motility.
Past Medical History:
Malrotation of Gut s/p surgery in ___
Bicuspid aortic heart valve
Social History:
___
Family History:
Pt adopted. Does not know family history
Physical Exam:
ON ADMISSION:
Physical Exam:
Vitals- T 98 BP 129/79 HR 46 RR 18 O2sat99% RA
GENERAL: pleasant young man laying comfortably in NAD
HEENT: Normocephalic, atraumatic. Sclera anicteric. No
conjunctival pallor or injection. PERRL. EOMI. Moist mucous
membranes, good dentition. Oropharynx is clear.
CARDIAC: RRR. bradycardic. Normal S1, S2. No m/r/g
LUNGS: CTA b/l. No wheezes, crackles, rhonchi
ABDOMEN: Hypoactive BS. Soft, nondistended, tender diffusely
but worse in the RLQ.
EXTREMITIES: Warm, well, perfused. No ___ edema. Palpable pulses
SKIN: No evidence of ulcers, rash or lesions.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation.
ON DISCHARGE:
Physical Exam:
Vitals- T 98.4 BP 109-129/53-79 HR 46-51 R 18 O2sat 99% on RA
GENERAL: pleasant young man laying comfortably in NAD
HEENT: Normocephalic, atraumatic. Sclera anicteric. No
conjunctival pallor or injection. PERRL. EOMI. Moist mucous
membranes, good dentition. Oropharynx is clear.
CARDIAC: RRR. bradycardic. Normal S1, S2. No m/r/g
LUNGS: CTA b/l. No wheezes, crackles, rhonchi
ABDOMEN: +BS. Soft, nondistended, mildly tender in RUQ, worse
in RLQ.
EXTREMITIES: Warm, well, perfused. No ___ edema. Palpable pulses
SKIN: No evidence of ulcers, rash or lesions. dry skin in the
back
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation.
Pertinent Results:
ADMISSION LABS:
___ 11:00AM BLOOD WBC-11.8* RBC-4.58* Hgb-14.6 Hct-42.4
MCV-93 MCH-31.9 MCHC-34.4 RDW-12.0 RDWSD-40.7 Plt ___
___ 11:00AM BLOOD Neuts-83.1* Lymphs-9.2* Monos-6.6
Eos-0.3* Baso-0.2 Im ___ AbsNeut-9.77* AbsLymp-1.08*
AbsMono-0.78 AbsEos-0.03* AbsBaso-0.02
___ 11:00AM BLOOD Plt ___
___ 11:00AM BLOOD Glucose-101* UreaN-9 Creat-0.8 Na-143
K-4.2 Cl-104 HCO3-26 AnGap-17
___ 11:00AM BLOOD Lipase-36
___ 11:00AM BLOOD Albumin-4.7
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-6.0 RBC-4.15* Hgb-13.2* Hct-38.9*
MCV-94 MCH-31.8 MCHC-33.9 RDW-12.3 RDWSD-42.2 Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-98 UreaN-8 Creat-0.9 Na-140 K-4.1
Cl-104 HCO3-26 AnGap-14
___ 08:00AM BLOOD HIV Ab-Negative
MICROBIOLOGY:
___ 1:50 pm URINE Source: ___.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
IMAGING:
CT A&P (___): No bowel obstruction. Congenitally malrotated
bowel is unchanged in
configuration to prior CT. No acute abdominopelvic process.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Abdominal Pain
Secondary:
Intestinal Malrotation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: +PO contrast; History: ___ with n/v, abd pain, hx of
malrotation+PO contrast // malrotation? SBO?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 52.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 399.0
mGy-cm.
2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP =
16.9 mGy-cm.
Total DLP (Body) = 416 mGy-cm.
COMPARISON: CT abdomen ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The majority of
the small bowel is in the right abdomen and the majority of the large bowel is
in the left abdomen, similar to prior and compatible with provided history of
malrotation. The colon and rectum are otherwise within normal limits. The
appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. Bilateral
ureteral jets are seen. There is no free fluid in the pelvis. Left lower
quadrant surgical clips are similar to prior.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No bowel obstruction. Congenitally malrotated bowel is unchanged in
configuration to prior CT. No acute abdominopelvic process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Vomiting, unspecified
temperature: 98.4
heartrate: 47.0
resprate: 18.0
o2sat: 100.0
sbp: 168.0
dbp: 107.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ is a ___ year old gentleman hx of malrotation of gut
s/p surgical intervention presents with nausea, vomiting,
abdominal pain x1 week. CT scan negative for any acute process.
Pt initially had leukocytosis w/ left shift, and WBCs in the UA.
Pt was tested for HIV, GC/chlamydia, which are pending on
discharge. Pt was given IV fluids and Zofran with resolution of
symptoms. Pt tolerated full PO diet and his symptoms improved,
and he was stable for discharge home.
#Abdominal Pain/Nausea/Vomiting
No clear source for patient's GI symptoms. Possible that patient
has cyclic vomiting syndrome given patient has chronic hx of
nausea/vomiting and has been symptom free for several months,
and pt also has hx of migraines which is associated with ___.
Also suspect patient may have some sort of gastroparesis given
hx of slow motility on gastric emptying study, possibly related
to his hx of malrotation. With history of marijuana use, was
intrigued at the possibility of cannabis hyperemesis syndrome.
However, pt does not endorse any behavioral shower relief and pt
stopped using marijuana for 5 days now without resolution of
symptoms. Given normal CT scan unchanged from before, no concern
for bowel obstruction, IBD, or acute process. Does not appear to
be infectious gastroenteritis given only 1 episode of diarrhea.
No acute electrolyte abnormalities is reassuring.
Pt with leukocytosis w/ left shift on admission and WBCs in the
UA. Pt endorses high risk sexual activity and at risk for STI,
which could have precipitated his GI symptoms. Pt was tested for
HIV, GC/chlamydia, which are pending on discharge. Pt was given
IV fluids and Zofran with resolution of symptoms. Pt tolerated
full PO diet and his symptoms improved, and he was stable for
discharge home. Consider gastric emptying study to assess for
motility issues
#High risk sexual activity
Pt was tested for HIV, GC/chlamydia, which are pending on
discharge. Patient was encouraged to engage in safe sex practice
TRANSITIONAL ISSUES
============================
-f/u patient's GI symptoms. Consider getting a gastric emptying
study to assess for motility issues.
-f/u Urine GC/chlamydia. Treat if positive
-f/u HIV ab test
-encourage safe sex practice
#Code Status: Full Code
#Emergency Contact/HCP: ___ (Father) ___, ___
(Mother) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
Penicillins / Cephalosporins / ampicillin
Attending: ___.
Chief Complaint:
Left Foot Infection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with PMH of HTN and history of
osteomyelitis of the R foot presenting to the ED with c/o
worsening L foot infection. She presents with swelling and
erythema of the left great toe and dorsum of foot. 2 weeks ago
noticed a blister on the tip of her left great toe. She saw her
podiatrist who did a debridement and put her on antibiotics.
Xrays taken several weeks ago were negative of signs of osteo of
the L hallux. The wound improved but did not completely resolve.
On ___, she noticed redness and swelling of the great toe
that subsequently spread to the dorsum of her foot and became
warm. She does not have any pain in the area but is neuropathic.
She denies fevers, nausea, vomiting or other systemic symptoms
of infection.
Past Medical History:
Right TKR
Left toe osteomyelitis s/p amputation
Obesity
Hypertension
Depression
Osteoarthritis
Social History:
___
Family History:
Father has history of MI
Physical Exam:
On Admission:
VS: 98.7 80 119/70 14 97% RA
GEN: NAD, A&Ox3
LLE: ___ pulses palpable. Cap refill <3 seconds to all digits.
L hallux with edema and erythema. erythema does not extend up
the foot and is localized to the L hallux. callus to the distal
aspect of the L hallux which after debridement revealed an
ulceration which probes deeply to bone. No purulence expressed
from the wound. hallux rigidus deformity with no ROM of the L
___ MPJ. No motion noted at the hallux IPJ.
On Discharge:
AVSS
GEN: NAD, A&Ox3
RESP: CTA
CV: RRR
ABD: Soft, NT, ND.
LLE: ___ pulses palpable. Cap refill <3 seconds to all digits.
L hallux with edema and erythema. erythema does not extend up
the foot and is localized to the L hallux decreased from
admission. ulceration to the distal aspect of the hallux 0.5 x
0.5 cm which probes deeply to bone. No purulence expressed from
the wound. hallux rigidus deformity with no ROM of the L ___
MPJ. No motion noted at the hallux IPJ. No pain on palpation of
the L hallux.
NEURO: CNII-XII intact. mentating appropriately. light touch
sensation diminished to b/l ___.
Pertinent Results:
On admission:
___ 05:30PM BLOOD WBC-11.2* RBC-4.51 Hgb-12.9 Hct-39.9
MCV-89 MCH-28.6 MCHC-32.3 RDW-13.2 RDWSD-42.2 Plt ___
___ 05:30PM BLOOD Neuts-76.1* Lymphs-15.6* Monos-6.3
Eos-1.1 Baso-0.4 Im ___ AbsNeut-8.49* AbsLymp-1.74
AbsMono-0.70 AbsEos-0.12 AbsBaso-0.04
___ 05:30PM BLOOD Plt ___
___ 05:30PM BLOOD Glucose-131* UreaN-24* Creat-0.8 Na-134
K-6.8* Cl-97 HCO3-24 AnGap-20
___ 05:52PM BLOOD Lactate-2.3* K-4.7
___ 05:30PM BLOOD CRP-43.3*
On Discharge:
___ 06:14AM BLOOD WBC-8.7 RBC-4.03 Hgb-11.8 Hct-36.6 MCV-91
MCH-29.3 MCHC-32.2 RDW-12.9 RDWSD-42.8 Plt ___
___ 06:14AM BLOOD Plt ___
___ 06:14AM BLOOD Glucose-100 UreaN-16 Creat-0.7 Na-142
K-3.8 Cl-101 HCO3-28 AnGap-17
___ 06:14AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
IMAGING:
L Foot X-Ray ___: A bandage overlies the big toe. Soft
tissue defect is noted at the big toe, likely ulceration. There
is lucency through the distal aspect of the first distal
phalanx, worrisome for acute osteomyelitis. Additional region
of lucency just proximal to this appears to have subtle early
sclerotic margins and may not be acute. Moderate osteoarthritic
changes are seen at the first interphalangeal joint in the
distal phalanx is subluxed laterally in relation to the first
proximal phalanx. Hammertoe deformities are seen. A plantar
calcaneal spur is seen. There is also posterior calcaneal
enthesophyte. Degenerative changes are seen along the dorsal
aspect of the tarsal bones.
MICRO:
___ 7:53 pm SWAB Source: L Foot .
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.25 mg PO BID
2. Hydrochlorothiazide 50 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. FLUoxetine 40 mg PO DAILY
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. ClonazePAM 0.25 mg PO BID
2. FLUoxetine 40 mg PO DAILY
3. Hydrochlorothiazide 50 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
6. Docusate Sodium 100 mg PO BID:PRN cosntipation
7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Ok to take non narcotic alternative
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
take with food
9. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*28 Tablet Refills:*0
10. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*42 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
L Foot Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with left foot pain, redness, swelling, fluctuance,
recent ulceration. // ?osteomyelitis, abcess
TECHNIQUE: Left foot, four views
COMPARISON: ___
FINDINGS:
A bandage overlies the big toe. Soft tissue defect is noted at the big toe,
likely ulceration. There is lucency through the distal aspect of the first
distal phalanx, worrisome for acute osteomyelitis. Additional region of
lucency just proximal to this appears to have subtle early sclerotic margins
and may not be acute. Moderate osteoarthritic changes are seen at the first
interphalangeal joint in the distal phalanx is subluxed laterally in relation
to the first proximal phalanx. Hammertoe deformities are seen. A plantar
calcaneal spur is seen. There is also posterior calcaneal enthesophyte.
Degenerative changes are seen along the dorsal aspect of the tarsal bones.
IMPRESSION:
Findings highly worrisome for acute osteomyelitis of the distal aspect of the
first distal phalanx; lucency through the distal aspect of the first distal
phalanx, worrisome for acute osteomyelitis. Additional region of lucency just
proximal to this appears to have subtle sclerotic margins and may not be
acute.
A bandage overlies the first toe and there is underlying ulceration and
possibly soft tissue gas.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Local infection of the skin and subcutaneous tissue, unsp
temperature: 98.7
heartrate: 80.0
resprate: 14.0
o2sat: 97.0
sbp: 119.0
dbp: 70.0
level of pain: 2
level of acuity: 3.0 | The patient was admitted to the podiatric surgery service from
the ED on ___ for a Left foot infection. On admission, she
was started on broad spectrum antibiotics and monitored for
improvement.
The patient remained afebrile with stable vital signs. Her WBC
count normalized. Her pain was well controlled oral pain
medication on a PRN basis. The patient remained stable from
both a cardiovascular and pulmonary standpoint. She was placed
on clindamycin and ciprofloxacin while hospitalized and
discharged with oral antibiotics. Her intake and output were
closely monitored and noted to be adequtae. The patient refused
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged.
The patient was subsequently discharged to home on HD3 with plan
for her to go to the OR on ___ for outpatient surgery.
The planned procedure is a partial Left Hallux amputation. The
patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Head and facial Trauma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old, previously healthy, ___ speaking male who
presents to emergency room s/p facial trauma. Per ED notes,
patient fell from 10 to 12 feet while at work lifting hay. This
story was corroborated by his coworker. There was no loss of
consciousness, or inciting event noted. Per patient he denies
experiencing any new onset headache, dizziness, changes in
vision, heart palpitations, or lightheadedness prior to the
fall. He states that he hit his face first and got up woozy, but
finds it difficult to recall events afterwards. He was taken to
___ for evaluation, where a CT Head was
significant for a Left orbital floor fracture, and
pneumocephalus. No
intracranial bleed or hematoma was noted. He was then
transferred to ___ hemodynamically stable for further
evaluation. Currently he complains about left face pain, and
right knee pain. No nausea, vomiting, fatigue, malaise, signs of
increased intracranial pressure, or signs of CSF leak.
Past Medical History:
none
Social History:
___
Family History:
N/C
Physical Exam:
Vitals: 98.3 70 112/61 18 100%RA
GEN: A&Ox3, NAD
HEENT: Left orbital mild swelling, mild tender to
palpation along orbit. EOMI, PERRL, no lacerations, auditory
canal intact, no hemotympanum. No cervical neck tenderness,
+FROM, ___ strength.
CV/Chest: RRR, no sternal/rib tenderness, no retractions, no
trauma, no lacerations
PULM: No respiratory distress Clear to auscultation b/l, No
W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No TTP Right knee, minimal pain with AROM, no pain with
PROM. +FROM. No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 02:15PM ___ 02:15PM ___ PTT-24.7* ___
___ 02:15PM PLT COUNT-270
___ 02:15PM WBC-17.4* RBC-5.17 HGB-13.5* HCT-41.1 MCV-80*
MCH-26.1 MCHC-32.8 RDW-13.8 RDWSD-39.9
___ 02:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 02:15PM LIPASE-18
___ 02:15PM estGFR-Using this
___ 02:15PM UREA N-16 CREAT-0.8
___ 02:29PM HGB-14.2 calcHCT-43
___ 02:29PM COMMENTS-GREEN TOP
Radiology Report
INDICATION: ___ with fall off height // eval for trauma
COMPARISON: None
FINDINGS:
AP, lateral, oblique views of the right knee provided. No fracture,
dislocation or evidence of joint effusion. An enthesophytes is seen along the
superior pole of the patella. No significant degenerative joint disease.
Mild prepatellar soft tissue swelling is noted.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: History: ___ with facial fracture, pneumocephalus. Eval for acute
process.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
Please note that there were some technical issues during the contrast
injection for the CTA and a second contrast bolus was injected. As a result,
the CTA is a combination of arterially and venous phase.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
1,003.4 mGy-cm.
4) Sequenced Acquisition 6.0 s, 6.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
301.0 mGy-cm.
5) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
6) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
7) Spiral Acquisition 3.0 s, 23.3 cm; CTDIvol = 31.3 mGy (Head) DLP = 730.8
mGy-cm.
Total DLP (Head) = 2,098 mGy-cm.
COMPARISON: Prior head CT from ___.
FINDINGS:
The study is moderately degraded by motion. Within these confines:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction or hemorrhage. The ventricles and sulci
are normal in size and configuration. No midline shift is seen.
There are multiple fractures including a fracture through the left temporal
bone as seen on image to 2a: 20, lateral wall of the left orbit on image
2a:16, superior wall of the left orbit extending into the left frontal sinus,
left zygomatic arch on image 2a:14, medial wall of the left orbit on image 2a
: 19. There is a possible fracture through the lateral wall of the right
sphenoid sinus. The previously seen fracture through the lateral wall of the
left maxillary sinus is not well visualized on the current CT. There is
associated intracranial and intraorbital pneumocephalus, increased compared to
the prior study with air within the subdural and subarachnoid space. Air in
the subdural space along the left frontal convexity exerts minimal mass effect
on the underlying brain parenchyma.
There is layering fluid in the left maxillary sinus. Also seen is fluid
opacification of bilateral ethmoid air cells and layering fluid in the right
sphenoid sinus. Bilateral mastoid air cells are clear.
There is pneumocephalus within the left orbit related to the known fracture of
medial orbital wall. The orbit is otherwise unremarkable without retrobulbar
hematoma.
Left preorbital soft tissue swelling and subcutaneous hematoma and emphysema
on image 2a: 19- 32.
CTA HEAD:
Of note there is a technical issue regarding the contrast injection and a
second contrast bolus was given, so to the CTA represents a combination of
venous and arterial phases.
The vessels of the circle of ___ and their principal intracranial branches
appear normal with no evidence of stenosis,occlusion or aneurysm. The dural
venous sinuses are patent.
Incidentally seen is dominant left vertebral artery and hypoplastic right A1
segment of the anterior cerebral artery.
IMPRESSION:
1. Allowing for normal anatomic variations, unremarkable head CTA.
2. No acute intra infarct or hemorrhage.
3. Multiple fractures involving the calvarium with slight interval progression
of intracranial pneumocephalus as described above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ s/p fall at work p/f OSH with Pneumocephalus, L frontal sinus
fx, L temporal bone fx, L orbital floor fx, L sphenoid fx, L maxillary sinus
fx. Interval assessment.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: DLP: 1404.79 mGy
CTDI: 50.1 mGy
COMPARISON: CTA head ___.
FINDINGS:
Slightly limited evaluation due to patient motion.
Interval decrease in pneumocephalus including a collection overlying the left
frontal lobe, with scattered locules of air overlying the bilateral
convexities and extending into the basal cisterns as well as overlying the
cerebellum. There is mild mass effect from the collection overlying the left
frontal lobe effacing the sulci without shift of normally midline structures.
The basal cisterns are patent. No acute large territorial infarction. No
intracranial hemorrhage.
Numerous facial fractures including nondisplaced fractures of the left
superior orbital rim with mildly displaced medial, and lateral orbital rim
fractures with extension to the left frontal sinus. Mildly displaced
transverse fracture through the left zygomatic arch is unchanged. Fracture
extends through the Left temporal bone and lateral wall of the left maxillary
sinus. Possible nondisplaced right sphenoid sinus fractures again noted.
Layering blood products are again seen within the left maxillary sinus, right
sphenoid sinus and within the ethmoidal air cells.
Again seen is a moderate subgaleal hematoma along the left temporal bone.
Subcutaneous emphysema seen along the left globe with retrobulbar are
involvement. No retrobulbar hematoma. Globes are intact. No evidence of
vitreous hemorrhage. Interval increase in deformity of the left optic nerve.
The ventricles and sulci are normal in size and configuration.
The additional visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The globes are intact.
IMPRESSION:
1. Decrease in pneumocephalus with no significant change in multiple facial
fractures with blood products within the left maxillary sinus, right sphenoid
sinus, and ethmoidal air cells.
2. Progression of left optic nerve deformity by the lateral orbital wall
fracture.
NOTIFICATION: The findings were discussed by Dr. ___ with ___ on
the telephone on ___ at 6:22 AM, minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CT ORBITS, SELLA AND IAC W/ CONTRAST Q1215 CT HEADSUB
INDICATION: ___ year old man with tbone fx. Temporal bone CT to eval fx. Thin
slices please per ENT request.
TECHNIQUE: Routine MDCT study of temporal bone was performed with coronal
reconstructions.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.5 s, 11.4 cm; CTDIvol = 138.9 mGy (Head) DLP =
1,578.3 mGy-cm.
Total DLP (Head) = 1,578 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
Slightly limited evaluation due to patient motion.
Left : A minimally displaced left temporal bone fracture is seen. The
external auditory canal is normal. The middle ear cavity is clear. The
ossicles and tegmen are intact. There is no evidence for enlarged vestibular
aqueduct or superior semicircular canal dehiscence. The facial nerve follows a
normal course through the middle ear. There is no evidence for inner ear
dysplasia. The mastoids are clear.
Right: The external auditory canal is normal. The middle ear cavity is clear.
The ossicles and tegmen are intact. There is no evidence for enlarged
vestibular aqueduct or superior semicircular canal dehiscence. The facial
nerve follows a normal course through the middle ear. There is no evidence for
inner ear dysplasia. The mastoids are clear.
Other: Facial fractures as described in previous noncontrast head CT as well
as hemorrhage within the left maxillary sinus, right sphenoid sinus and
ethmoidal air cells.
IMPRESSION:
1. Minimally displaced left squamus temporal bone fracture with multiple
facial fractures better characterized on prior head CT, including left lateral
and medial maxillary wall, and left zygomatic arch fractures with hemorrhage
in the left maxillary sinus, right sphenoid sinus and ethmoidal air cells.
2. Otherwise normal temporal bone CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with pneumocephalus. Assess pneumocephalus.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 17.2 cm; CTDIvol = 46.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Noncontrast head CT ___, CT orbits ___.
FINDINGS:
Decrease in pneumocephalus, with small amount of air along the left frontal
lobe with few locules of air along the falx and left frontal lobe. There is
persistent but improved mass effect along the left frontal lobe with mild
sulcal effacement. No shift of normally midline structures. The basal
cisterns are patent. No acute large territorial infarction. No intracranial
hemorrhage. The ventricles and sulci are normal in size in appearance.
Again seen are multiple facial fractures including nondisplaced fracture of
the left superior orbital rim, mildly displaced medial and lateral orbital rim
fractures with extension to the left frontal sinus. Mildly displaced
transverse fractures of left zygomatic arch is unchanged. Fractures extend
through the left temporal bone and lateral wall of the left maxillary sinus.
Again seen is a possible nondisplaced fracture through the right sphenoid
sinus. Layering blood products are seen within the right sphenoid sinus and
within the ethmoidal air cells.
Left temporal soft tissue subgaleal hematoma has decreased in size.
Subcutaneous emphysema is seen along the left globe with retrobulbar
involvement. No retrobulbar hematoma. Globes are intact. No evidence of
vitreous hemorrhage. Again seen is deformity of the left optic nerve, which
is unchanged since prior examination.
IMPRESSION:
1. Decreased pneumocephalus without significant change in multiple facial
fractures with blood products within the right sphenoid sinus and ethmoidal
air cells.
2. Persistent left optic nerve deformity by the lateral orbital wall fracture.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: Head injury
Diagnosed with Oth fracture of base of skull, init for clos fx, Unsp intracranial injury w/o loss of consciousness, init, Fracture of orbital floor, init encntr for closed fracture, Maxillary fracture, unspecified side, init, Other specified disorders of brain, Other fall from one level to another, initial encounter
temperature: 97.9
heartrate: 70.0
resprate: 14.0
o2sat: 100.0
sbp: 132.0
dbp: 81.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ was admitted to the ICU after his fall of ___ feet
because his imaging findings included pneumocephalus as well as
multiple facial fractures, for which neurosurgery, plastic
surgery, and ENT were consulted.
N: There was a concern for possible CSF leak, and he required
q1h neuro checks. A CTA was obtained on HD2 that did not show
any signs of bleeding, and he was AOx3 and neuro intact
throughout his entire hospitalization. He was originally kept
flat for 48 hours, and then sat up to assess for CSF leak. none
was identified and he was allowed to space out his neuro checks.
Repeat CT head 48 hours after admission showed improved
pneumocephalus, and there continued to be no signs of a leak.
The following day his neuro checks were spaced out and he
continued to be neuro intact, so he was transferred to the
floor.
CV: no issues with his blood pressure throughout his hospital
stay.
P:
GI: |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Novocain / Lipitor / Codeine / Crestor / metoprolol / Zetia /
atenolol / gabapentin / pravastatin
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with history of CAD on
plavix, hip fracture, hypertension, bradycardia and falls
presenting after a recurrent fall. Patient cannot give a history
as she does not remember the event but was found on the floor of
her room at ___ and had a hematoma on her head. The
fall was unwitnessed. Patient is confused at baseline. Denies
any pain, lightheadedness, headache, worsening confusion,
difficulty speaking, shortness of breath, chest pain, abdominal
pain and dysuria. She says she feels fine but knows she is here
because of a fall.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems (10) were reviewed and are negative.
ED Course: VSS, BP 101/60 forehead hematoma, TTP in suprapubic
region WBC 11.4, UA positive CT head/neck unremarkable Received
one dose CTX for UTI.
Past Medical History:
Abdominal pain
Stercoral versus infectious colitis
Severe constipation
Weakness
Bradycardia
Diet-controlled Type II diabetes
Hypertension
Coronary artery disease
Carotid stenosis
Hypothyroidism
Hyperlipidemia
GERD
Neuropathy
Social History:
___
Family History:
- mother - deceased - heart disease
- father - deceased - lung cancer
Physical Exam:
AFVSS
GENERAL: Alert and in no apparent distress. Lying almost flat in
bed.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen is soft, non-distended, minimally tender to
palpation in lower abdomen without rebound or guarding. Bowel
sounds present.
GU: No suprapubic tenderness
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rash noted.
NEURO: Alert, oriented to person but not place ("I'm in a
clinic") or year (___). Knows she is here for a fall. Face
symmetric, gaze conjugate with EOMI, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Patient examined on day of discharge.
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
===========================
___ 01:05PM BLOOD WBC-9.3 RBC-3.72* Hgb-11.8 Hct-38.0
MCV-102* MCH-31.7 MCHC-31.1* RDW-14.6 RDWSD-54.9* Plt ___
___ 01:05PM BLOOD Glucose-109* UreaN-16 Creat-0.8 Na-140
K-4.4 Cl-104 HCO3-28 AnGap-8*
___ 12:55AM BLOOD ALT-6 AST-10 AlkPhos-84 TotBili-0.2
MICRO:
=====
___ UA with > 182 WBCs
___ UA with 12 WBCs
___ UCx pending on discharge
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
GRAM POSITIVE RODS. >100,000 CFU/mL. UNABLE TO
IDENTIFY FURTHER.
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
IMAGING/OTHER STUDIES:
=====================
CT Head ___
IMPRESSION:
Small focus of subarachnoid hemorrhage in a left frontal sulcus
is stable in size with decreased density. No new intracranial
hemorrhage.
CT C-spine ___
IMPRESSION:
No evidence for a fracture. No subluxation.
LABS ON DISCHARGE:
=================
___ 01:05PM BLOOD WBC-9.3 RBC-3.72* Hgb-11.8 Hct-38.0
MCV-102* MCH-31.7 MCHC-31.1* RDW-14.6 RDWSD-54.9* Plt ___
___ 01:05PM BLOOD Glucose-109* UreaN-16 Creat-0.8 Na-140
K-4.4 Cl-104 HCO3-28 AnGap-8*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO BID
2. Clopidogrel 75 mg PO DAILY
3. Gabapentin 400 mg PO TID
4. Isosorbide Mononitrate (Extended Release) 15 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Senna 17.2 mg PO BID
8. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
9. Docusate Sodium 100 mg PO BID
10. Fleet Enema (Saline) ___AILY:PRN No bowel movement
in 24 hours despite other medications
11. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Pain
and irritation
12. Witch ___ 50% Pad ___SDIR QID PRN
13. Linzess (linaCLOtide) 145 mcg oral DAILY
14. Pravastatin 20 mg PO QPM
15. Esomeprazole 40 mg PO DAILY
16. Ciprofloxacin HCl 500 mg PO Q12H
17. MetroNIDAZOLE 500 mg PO Q8H
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
3. Docusate Sodium 100 mg PO BID
4. Esomeprazole 40 mg PO DAILY
5. Fleet Enema (Saline) ___AILY:PRN No bowel movement
in 24 hours despite other medications
6. Gabapentin 400 mg PO TID
7. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN Pain
and irritation
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Linzess (linaCLOtide) 145 mcg oral DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Pravastatin 20 mg PO QPM
12. Senna 17.2 mg PO BID
13. ___ ___ 50% Pad ___SDIR QID PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# mechanical fall
# recurrent UTI
# urinary retention
# Subarachnoid hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fall, belly pain, anticoagulated// eval brain
bleed, eval c spine injury, eval pneumothorax, eval abdominal bleed
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph performed ___.
FINDINGS:
Lungs are moderately well aerated. No large pleural effusion or pneumothorax.
The cardiomediastinal silhouette is normal. No evidence of acute cardiac
decompensation.
IMPRESSION:
Normal chest radiograph.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with fall, found on the floor with head bruising. Evaluate
for intracranial injury.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Brain MRI performed ___.
Head CT from ___.
FINDINGS:
Mild motion artifact is present.
A single linear hyperdense focus in a left frontal sulcus is seen on coronal
and sagittal reformatted images (601:24, 401:59), which may reflect a small
focus of his subarachnoid hemorrhage, versus motion artifact. No other
evidence for intracranial hemorrhage. No evidence for an acute major vascular
territorial infarct, edema, or mass effect. Mild periventricular and
subcortical white matter hypodensities are nonspecific but likely sequela of
chronic small vessel ischemic disease in this age group. Moderate global
parenchymal volume loss is again seen with prominent ventricles and sulci.
There is extensive calcification of bilateral carotid siphons and left greater
than right intracranial vertebral arteries.
There is mild right parietal subgaleal soft tissue swelling. There is no
evidence of fracture. There is minimal mucosal thickening in the ethmoid air
cells. Mastoid air cells and middle ear cavities are clear. The orbits
appear grossly unremarkable allowing for motion artifact.
IMPRESSION:
1. Possible single focus of subarachnoid hemorrhage in a left frontal sulcus,
versus motion artifact. No other evidence for intracranial hemorrhage.
2. No edema or CT evidence for an acute major vascular territorial infarction.
RECOMMENDATION(S): Repeated head CT for reassessment of the questionable
small focus of subarachnoid hemorrhage.
NOTIFICATION: The final interpretation and recommendation for repeat head CT
were discussed with ___, M.D. by ___, M.D. on the
telephone on ___ at 10:06 am, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with status post fall with head trauma. Evaluate
for cervical spine injury.
TECHNIQUE: Non-contrast helical multidetector CT of the cervical spine was
performed. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 19.0 cm; CTDIvol = 22.7 mGy (Body) DLP = 431.9
mGy-cm.
Total DLP (Body) = 432 mGy-cm.
COMPARISON: CT cervical spine performed ___.
FINDINGS:
No fractures are identified. No evidence for prevertebral soft tissue
swelling. No acute subluxation. Disc protrusions and endplate osteophytes
mildly indent the ventral thecal sac at multiple levels. Neural foraminal
narrowing by uncovertebral and facet osteophytes is seen at C3-C4 on the left,
C4-C5 and C5-C6 bilaterally, and C6-C7 on the right, up to moderate in
severity.
Concurrent head CT is reported separately. Right common and internal carotid
arteries are medialized, indenting the posterior pharyngeal wall. Bilateral
carotid artery calcifications are noted. The thyroid is small and low in
density, suggesting low iodine content. Visualized lung apices are
unremarkable.
IMPRESSION:
No evidence for a fracture. No subluxation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman on Plavix s/p unwitnessed fall with question of
subarachnoid hemorrhage vs artifact on initial CT head. Repeated head CT is
requested.
TECHNIQUE: Noncontrast head CT sagittal and coronal reformatted image.
DOSE:
Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.8 mGy (Head) DLP =
861.5 mGy-cm.
2) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 49.8 mGy (Head) DLP =
752.0 mGy-cm.
Total DLP (Head) = 1,614 mGy-cm.
COMPARISON: Head CT from ___ at 01:51, approximately 11 hours prior.
FINDINGS:
The previously noted small focus of linear hyperdensity in a left frontal
sulcus is stable in extent with decreased density, images 10:15, 11:15. No
new intracranial hemorrhage is seen. No edema, mass effect, or evidence for
an acute major vascular territorial infarction. Mild periventricular and
subcortical white matter hypodensities are again noted, nonspecific but likely
sequela of chronic small vessel ischemic disease in this age group. Moderate
global parenchymal volume loss is again seen with prominent ventricles and
sulci. Extensive calcification of bilateral carotid siphons and left greater
than right intracranial vertebral arteries is again noted.
Mild soft tissue swelling is again seen in the right parietal scalp. No
evidence for a fracture. Paranasal sinuses and mastoid air cells appear
grossly well-aerated allowing for absence of dedicated bone algorithm images.
IMPRESSION:
Small focus of subarachnoid hemorrhage in a left frontal sulcus is stable in
size with decreased density. No new intracranial hemorrhage.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Urinary tract infection, site not specified
temperature: 98.6
heartrate: 78.0
resprate: 17.0
o2sat: 99.0
sbp: 101.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ female with the past medical
history and findings noted above who presents after an
unwitnessed fall.
# Unwitnessed Fall
# Forehead hematoma
Fall unwitnessed (found lying on the floor in her room) but
bruise on forehead suggests headstrike. Pt does not recall the
event. CT head/neck with no intracranial abnormality. While
patient with history of 4:1 flutter, ECGs at baseline with HRs
in ___ and no documented events on tele > 48h. Cardiac enzymes
negative. No murmur on exam nor history of DOE to raise concern
for valvulopathy-mediated syncope. Noted to have borderline low
BPs so home amlodipine discontinued. Collateral obtained from
nursing staff at ___ and story seems consistent with mechanical
fall as patient noted to be impulsive with poor situational
awareness. Recommend continued rehab and fall precautions on
return. Unclear if UTI (see below) contributed in fall risk.
# SAH:
CT scan with very small SAH without mass effect or focal neuro
symptoms. She was evaluated by neurosurgery who concluded that
there was no need for intervention or follow up imaging. Plavix
was held and should not be given for at least two weeks.
However, given risk of recurrent falls, decision made to hold
indefinitely. Physician at ___ agrees.
#UTI
#Urinary retention:
UA on admission with pyuria with WBCs greater than assay. UCx
growing mixed flora. Treated with CFTX. Subsequently found to be
retaining urine and thus bladder placed. She was unable to
undergo CIC due to agitation with this, so foley left in place.
Given contaminated initial UCx, repeat obtained. UA with
significant reduction in pyuria indication response to CFTX so
she was transitioned to PO cefpodoxime to complete a seven day
course through ___. She will need a voiding trial at ___ with
PVRs closely monitored to determine need for CIC versus chronic
foley if not voiding spontaneously.
#Aflutter 4:1 block on ECG and tele with HRs stable in ___.
No documented bradycardia/tachycardia or other arrhythmia.
Continued BB. Patient not on anticoagulation and this was not
started in setting of SAH, however, given history of repeated
falls, likely risks > benefits.
# Hypertension:
Borderline low BPs noted. Imdur and amlodipine held. BB
continued.
# Subacute cognitive decline:
Per discussion with ___ staff, patient with intermittent
confusion and cognitive decline over past month since arrival.
Likely had been declining even longer. Consistent with
progressive dementia.
# Type II diabetes:
Diet controlled. No issues.
#Carotid stenosis:
Continued on statin but. Last U/S in ___ with only mild
stenosis. Plavix discontinued in setting of SAH, with plan to
not resume per discussion with PCP at ___.
# Hypothyroidism. - continued synthroid 88 mcg
# Neuropathy - continued gabapentin.
TRANSITIONAL ISSUES:
===================
[] Discharged with indwelling foley. Recommend voiding trial
with monitoring of PVRs. ___ require CIC if not spontaneously
voiding.
[] Recommend NOT resuming Plavix due to high fall risk.
> 30 mins spent planning discharge |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lipitor / Inapsine / Iodine / Tetanus / Cefodizime
/ Doxycycline Hyclate / IV Dye, Iodine Containing Contrast Media
/ Fosamax / Livalo / ampicillin / ___ / isoniazid / red
acetaminophen
Attending: ___.
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
Bilateral Trochanteric Bursa Steroid Injections (___)
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history of polymyalgia rheumatica, arthritis, bursitis, HTN,
hypothyroidism, fibromyalgia, chronic abdominal pain with
dyspepsia, osteopenia, and spinal stenosis s/p recent lumbar
laminectomy and posterior spinal fusion on ___ by Dr. ___,
presenting with bilateral hip pain. History is obtained from
the patient as well as the nursing supervisor at her facility.
She states that she has had various pains over the course of the
past ___ years after a fall. She is usually maintained on
Tylenol and Oxycodone by her PCP and also sees a pain
specialist. She was hospitalized from ___ on orthopedics
for L4-S1 lumbar laminectomy, L5-S1 posterior fusion on ___ and
discharged to rehab. She reports that she was able to
participate in the exercises initially with tolerable pain, but
over the next ___ days, had progressive, right and left hip pain
which was both sharp and throbbing. It was worse with walking,
and not precipitated by trauma. RNs tried giving her dilaudid,
position changes, ice packs, and salicylate cream, but these did
not help. She noted that this is not at the site of her surgery
which she refers to as her "bum" pain, which is still present,
but reasonably well controlled. She noted no leg
numbness/tingling that is new (chronic RLE numbness for months),
changes in bowel or bladder function, fevers, shaking chills, or
dysuria. She states that the pain in her other joints is not
particularly different that it is at baseline. As far as she
knows, her prednisone dose has not changed significantly over
the past month, though her MDs are trying to wean it down.
Vitals in the ER: 98.3 99 123/56 16 99% RA
There, the patient was seen by ortho who did not think that
there were any complications from the procedure and advised
admission to medicine. She received:
Morphine 2mg IV
Tylenol 1g PO
Gabapentin 100mg PO
Oxycodone 10mg PO
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
Fibromyalgia
Polymyalgia rheumatic on chronic prednisone (5mg/d)
h/o arthritis and bursitis bilaterally in her shoulders.
Chronic abdominal pain; work-up with GI reveals gastritis and
dyspepsia
Hepatic hemangiomas
Hoarse voice with likely laryngopharyngeal reflux per ENT
Spinal stenosis.
Osteopenia.
Cataracts bilaterally.
Hypothyroidism
s/p cholecystectomy.
h/o deviated septum s/p repair.
Insomnia
Chronic fatigue syndrome.
Allergic rhinitis (Reported)
Frequent asymptomatic urinary tract infections.
?Dermatographism (per patient)
___ s/p L4-S1 lumbar laminectomy, L5-S1 posterior fusion
Social History:
___
Family History:
Mother - diabetes ___, hypertension.
Father - CVA. Two aunts with breast cancer.
1 child with gastritis (stress related?)
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: (see eFlowsheet)
GENERAL: Alert and in no apparent distress, awake, interactive
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored
GI: Abdomen soft, non-distended, no hepatosplenomegaly
appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: right and left hip have pain with passive internal and
external rotation, right moreso with slight external rotation,
straight leg raise negative, some tenderness to palpation of
hips, Neck supple, normal muscle tone
SKIN: No rashes or ulcerations noted, back incision is healing
well, non-erythematous or tender
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: normal thought content, logical thought process,
appropriate affect
DISCHARGE PHYSICAL EXAM:
VS: 97.6 PO 152 / 64 R Lying 76 16 ___ppearing, comfortable lying in bed
MMM, OP clear
clear lungs throughout
___ systolic murmur at RUSB
Abdomen mildly distended, soft, nontender, no rebound
MSK: normal muscle tone in bilateral lower extremities, no ttp
over bilateral tronchanteric bursa or hips
Skin: Clean incision over lumbar spine
Neuro: ___ strength in bilateral lower extremities throughout,
oriented x3
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-13.2* RBC-3.66* Hgb-10.9* Hct-33.2*
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.8* RDWSD-51.5* Plt ___
___ 08:30PM BLOOD Neuts-73.9* Lymphs-15.9* Monos-6.9
Eos-0.5* Baso-0.2 Im ___ AbsNeut-9.78* AbsLymp-2.10
AbsMono-0.92* AbsEos-0.07 AbsBaso-0.03
___ 08:30PM BLOOD Plt ___
___ 08:30PM BLOOD Glucose-107* UreaN-20 Creat-0.8 Na-135
K-5.6* Cl-95* HCO3-23 AnGap-17
___ 05:06AM BLOOD Mg-1.9
___ 05:03AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.1
___ 08:30PM BLOOD CRP-40.2*
IMAGING:
- XR Hips (___): 1. No acute fracture, dislocation, or
radiographic evidence of inflammatory arthropathy.
2. Mild degenerative changes of the bilateral hips, which have
not significantly progressed compared to most recent prior
radiographs and MRI.
DISCHARGE LABS
___ 06:10AM BLOOD WBC-10.1* RBC-3.28* Hgb-9.7* Hct-31.0*
MCV-95 MCH-29.6 MCHC-31.3* RDW-16.2* RDWSD-56.6* Plt ___
___ 07:47AM BLOOD K-4.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
3. Cyclobenzaprine 10 mg PO TID
4. Acetaminophen 1000 mg PO TID
5. PredniSONE 9 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. Cetirizine 10 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Furosemide 20 mg PO DAILY
13. Ascorbic Acid ___ mg PO DAILY
14. Gabapentin 100 mg PO TID
15. Metoprolol Tartrate 37.5 mg PO BID
16. HydrALAZINE 10 mg PO BID
17. Docusate Sodium 100 mg PO BID
18. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
19. Salonpas (methyl salicylate-menthol) ___ % topical DAILY
20. Senna 17.2 mg PO QHS
21. Fleet Enema (Saline) ___AILY:PRN constipation
22. Bisacodyl ___AILY:PRN constipation
23. LORazepam 0.5 mg PO Q8H:PRN anxiety
24. Ondansetron ODT 4 mg PO Q8H:PRN nausea
25. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN
26. Heparin 5000 UNIT SC BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
Please continue for 1 month
2. Narcan (naloxone) 4 mg/actuation nasal ONCE
3. Polyethylene Glycol 17 g PO DAILY
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN BREAKTHROUGH PAIN
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
5. Acetaminophen 1000 mg PO TID
6. Ascorbic Acid ___ mg PO DAILY
7. Bisacodyl ___AILY:PRN constipation
8. Calcium Carbonate 500 mg PO DAILY
9. Cetirizine 10 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
11. Cyclobenzaprine 10 mg PO TID
12. Docusate Sodium 100 mg PO BID
13. Fluticasone Propionate NASAL 2 SPRY NU DAILY
14. Furosemide 20 mg PO DAILY
15. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times a day
Disp #*6 Capsule Refills:*0
16. HydrALAZINE 10 mg PO BID
17. Levothyroxine Sodium 88 mcg PO DAILY
18. LORazepam 0.5 mg PO Q8H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth every eight (8) hours
Disp #*3 Tablet Refills:*0
19. Metoprolol Tartrate 37.5 mg PO BID
20. Multivitamins 1 TAB PO DAILY
21. Omeprazole 20 mg PO DAILY
22. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
RX *oxycodone 10 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
23. PredniSONE 9 mg PO DAILY
24. Salonpas (methyl salicylate-menthol) ___ % topical DAILY
25. Senna 17.2 mg PO QHS
26. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral Trochanteric Bursitis
Inability to Ambulate
Elevated CRP
Thrombocytosis
Pseudohyperkalemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS
INDICATION: ___ year old woman with prior PMR, recent spinal surgery,
presenting with bilateral lateral hip pain (more over trochanter,),
symmetrical// ? fx, inflammatory changes.
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of bilateral hips.
COMPARISON: Radiographs of the pelvis and bilateral hips ___.
MRI pelvis ___.
FINDINGS:
RIGHT HIP:
There is diffuse osteopenia. There is no fracture or dislocation. There are
mild degenerative changes of the right hip. A linear calcific density
adjacent to the greater trochanter is unchanged and may represent calcific
tendinosis of the gluteal tendons.
LEFT HIP:
There is diffuse osteopenia. There is no fracture or dislocation. Mild
degenerative changes are again noted. There is no suspicious lytic or
sclerotic lesion. There is no soft tissue calcification or radio-opaque
foreign body.
PELVIS:
Posterior spinal fusion hardware is seen at the lumbosacral junction.
IMPRESSION:
1. No acute fracture, dislocation, or radiographic evidence of inflammatory
arthropathy.
2. Mild degenerative changes of the bilateral hips, which have not
significantly progressed compared to most recent prior radiographs and MRI.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED THERAPEUTIC STEROID/ANALGESIC INJECTION OF THE
RIGHT AND LEFT GREATER TROCHANTERIC BURSA
INDICATION: ___ year old woman with bilateral trochanteric bursa
inflammation/pain causing inability to ambulate- rheum recommending b/l
trochanteric bursa steroid injections by ___// b/l trochanteric bursa steroid
injections
TECHNIQUE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained and documented in the chart.
A pre-procedure timeout confirmed three patient identifiers.
Under ultrasound guidance, an appropriate spot was marked overlying the right
trochanteric bursa. The area was prepared and draped in standard aseptic
fashion.
5 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
ultrasound guidance, a 22-gauge spinal needle was advanced into the right
trochanteric bursa. Then, a solution containing 40mg of Kenalog and 2cc of
0.25% bupivicaine was injected into the right trochanteric bursa. Needle
removed, bandage applied.
Under ultrasound guidance, an appropriate spot was marked overlying the left
trochanteric bursa. The area was prepared and draped in standard aseptic
fashion.
5 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
ultrasound guidance, a 22-gauge spinal needle was advanced into the left
trochanteric bursa. Then, a solution containing 40mg of Kenalog and 2cc of
0.25% bupivicaine was injected into the left trochanteric bursa. Needle
removed, bandage applied. .
The patient tolerated the procedure well and left the department in good
condition. There were no immediate complications. Informed discharge given.
COMPARISON: None
FINDINGS:
On the right, there is trace fluid in the greater trochanteric bursa.
On the left, enthesopathic changes of the posterior facet of the greater
tuberosity, with tendinosis and probable partial thickness tears of the
gluteus medius.
IMPRESSION:
Technically successful and uncomplicated ultrasound-guided injection of
anesthetic and steroid into the greater trochanteric bursa bilaterally.
I Dr. ___ personally supervised the Resident/Fellow during the key
components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Wound eval
Diagnosed with Other acute postprocedural pain
temperature: 97.8
heartrate: 90.0
resprate: 20.0
o2sat: 96.0
sbp: 130.0
dbp: 50.0
level of pain: 10
level of acuity: 3.0 | Mrs. ___ is a ___ woman with history
of PMR (on chronic prednisone), hypothyroidism, fibromyalgia,
chronic abdominal pain with dyspepsia, and spinal stenosis s/p
recent lumbar laminectomy and posterior spinal fusion on ___ by
Dr. ___, admitted with bilateral hip pain thought to be from
trochanteric bursisitis, superimposed on her postoperative
pains, with inability to ambulate.
# Bilateral hip pain
# Trochanteric Bursitis
# Inability to ambulate: Patient evaluated by spine in the ED
who felt that there was low concern for infection given clean
appearance of surgical site and for lack of neurologic symptoms.
They recommended against imaging at that time. There was
initially concern for a flare of PMR based on elevated CRP and
patient was started on higher dose steroids. However,
rheumatology consult felt symptoms were more consistent with
bilateral trochanteric bursitis. Steroids were returned to
___ dosing and patient underwent bilateral trochanteric
bursitis injection. With treatment, her symptoms improved
significantly and she was able to walk to the chair with
assistance from nursing.
# Spinal Stenosis, s/p
# Recent lumbar laminectomy and posterior spinal fusion:
Orthopedics saw in ED, low concern for infection given
appearance of surgical site and for lack of neuro symptoms.
Recommended against imaging. Patient remained without concerning
neurologic features for the duration of her hospital course.
Strength was ___ in bilateral lower extremities throughout on
discharge. Per discussion with Dr. ___ surgeon),
aspirin 81mg was started at discharge to prevent clotting and SC
heparin stopped. Please continue for 1 month post-operatively.
# Thrombocytosis
# Elevated CRP:
Patient admitted with elevated CRP and thrombocytosis (950)
which may have been related to recent spinal surgery.
Thrombocytosis improved over course of admission suggesting
resolving process.
# Hyperkalemia: Serum potassium was initially elevated to 5.6.
There was a large discrepancy between plasma and serum potassium
which was suspected due to pseudohyperkalemia in the setting of
thrombocytosis (>900).
# Polypharmacy: Patient on high doses of narcotic pain meds,
benzodiazepines and muscle relaxants concerning given patient's
age. Discussed extensively with patient who is amenable to
weaning her medications as her post-operative course improves.
Please work with patient to wean narcotic pain medications as
able given ongoing improvement in her pain post-operatively. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
scrotal cellulitis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o morbid obesity, obesity hypoventillation on chronic 02,
not compliant with nocturnal bipap, diastolic CHF, current
resident at ___ since ___ who is transferred from ___ for evaluation of scrotal cellulitis with question of
___ Gangrene. Urology at ___ evaluated patient and
there is no signs of necrotizing infection either clinically or
with evaluation with CT pelvis performed at ___. Patient has
not had fevers. He is poor historian other than remarking on
recent chills. Has had issues with chronic scrotal swelling.
SNF progress note by Dr. ___ on ___ documents: acute
diastolic heart failure with significant scrotal edema for which
physician ordered scrotal elevation, increased lasix dose to
80mg and use of zaroxolyn 2.5mg every other day. Scrotum is
mildly tender
13pt review only notable for singificant >100kg weight gain in
past ___ years after depressive episode and psych hospitilzation
for suicidal ideation.
Past Medical History:
morbid obesity
obesity hypoventilation
nocturnal bipap, not compliant
diastolic chf
hypertension
type 2 diabetes on insulin
hypercholesterolemia
anxiety/depression
gerd
Social History:
___
Family History:
not pertinent to current admit dx
Physical Exam:
98.3 110/64 80 22 84% on RA, 92% on 4L NC
morbidly obese
poor dental hygeine, dry lips
clear BS,
regular s1 and s2
jvp obscured by habitus
soft obese non-tender abd
inverted penis,
large swollen scrotum with erythema, no crepitus or areas of
skin necrosis, no perineal fluctuance or pustules. poor skin
hygeine in groin
pitting peripheral edema with chronic venous stasis changes
aox3, odd affect
Discharge exam
afebrile, VSS, hypoxic at night without BiPAP
morbidly obese
poor dental hygeine, MMM
clear lungs bilaterally
regular s1 and s2
jvp obscured by habitus
soft obese non-tender abd
inverted penis,
large swollen scrotum without erythema, no crepitus or areas of
skin necrosis, no perineal fluctuance or pustules. poor skin
hygeine in groin
trace peripheral edema with chronic venous stasis changes
A and O x 3, anxious at times
Pertinent Results:
___ 10:20PM BLOOD WBC-12.0* RBC-4.86 Hgb-14.1 Hct-44.4
MCV-91 MCH-29.0 MCHC-31.7 RDW-14.1 Plt ___
___ 10:20PM BLOOD Glucose-159* UreaN-20 Creat-1.0 Na-139
K-3.8 Cl-89* HCO3-38* AnGap-16
___ 10:20PM BLOOD Neuts-71.9* Lymphs-17.9* Monos-5.8
Eos-3.6 Baso-0.8
___ 10:20PM BLOOD Calcium-8.8 Phos-2.3* Mg-1.8
___ 11:30PM BLOOD Lactate-1.0
ct pelvis
___ ___ M ___ ___
Radiology Report CT PELVIS W/O CONTRAST Study Date of ___
1:46 AM
___ ___ 1:46 AM
CT PELVIS W/O CONTRAST Clip # ___
Reason: eval for ___, gas
UNDERLYING MEDICAL CONDITION:
NO_PO contrast; History: ___ with scrotal swelling, edema
REASON FOR THIS EXAMINATION:
eval for ___, gas
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: ___ SAT ___ 3:32 AM
Extensive anterior abdominal wall and pannus skin thickening and
fat stranding
extending into the scrotum with large bilateral hydroceles. No
subcutaneous
gas detected. Although no subcutaneous gas is detected,
Forniere's gangrene
cannot be definitively excluded.
Wet Read Audit # 1 ___ SAT ___ 3:31 AM
Extensive anterior abdominal wall and pannus skin thickening and
fat stranding
extending into the scrotum with large bilateral hydroceles. No
subcutaneous
gas detected. Findings are concerning for Forniere's gangrene.
Final Report
HISTORY: ___ male with scrotal swelling and edema.
COMPARISON: Outside hospital CT dated ___.
TECHNIQUE: CT of the pelvis was performed without intravenous
contrast.
Multiplanar reformatted images were reviewed.
FINDINGS:
Extensive subcutaneous edema is seen in the anterior pelvic
subcutaneous fat
with skin thickening and edema of the pannus. This edema
extends into the
scrotum and is very severe. There are very large bilateral
hydroceles. No
subcutaneous gas is detected. The urinary bladder and imaged
colon contain
contrast material. No other acute abnormalities are detected in
the imaged
portion of the pelvis. Degenerative changes in the lumbar spine
are not well
evaluated on this study.
IMPRESSION:
Extensive subcutaneous and scrotal edema and fluid without CT
evidence for
subcutaneous gas.
The study and the report were reviewed by the staff radiologist.
cxr:
IMPRESSION:
Low lung volumes without acute findings in the upper lung
fields. Small right
pleural effusion cannot be excluded.
Discharge labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.1 4.85 14.5 46.5 96 29.9 31.2 13.9 337
UreaN Creat Na K Cl HCO3
15 0.9 140 3.9 91* 43
urine culture no growth
blood culture no growth
ultrasound: No evidence of deep vein thrombosis in the left
lower extremity
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. BusPIRone 50 mg PO TID
5. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
6. Fluoxetine 60 mg PO DAILY
7. glimepiride 2 mg oral qd
8. HydrOXYzine 25 mg PO Q6H:PRN itch
9. Ibuprofen 600 mg PO Q8H:PRN pain
10. MetFORMIN (Glucophage) 850 mg PO BID
11. Simvastatin 20 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
14. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN wheeze
15. nystatin 100,000 unit/gram topical bid
16. Furosemide 100 mg PO DAILY
17. Bisacodyl 10 mg PO DAILY:PRN constipation
18. Milk of Magnesia 30 mL PO Q6H:PRN upset stomach
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
2. Albuterol-Ipratropium ___ PUFF IH Q4H:PRN wheeze
3. Amlodipine 5 mg PO DAILY
4. BusPIRone 30 mg PO TID
5. Fluoxetine 60 mg PO DAILY
6. Furosemide 100 mg PO DAILY
7. HydrOXYzine 25 mg PO Q6H:PRN itch
8. Ibuprofen 600 mg PO Q8H:PRN pain
9. Tamsulosin 0.4 mg PO HS
10. Aspirin 81 mg PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Simvastatin 20 mg PO DAILY
13. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
14. Glargine 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
15. MetFORMIN (Glucophage) 850 mg PO BID
16. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
17. Sulfameth/Trimethoprim DS 1 TAB PO BID
last day ___
18. Cephalexin 500 mg PO Q6H
last day ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
morbid obesity
scrotal cellulitis and edema
obesity hypoventillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with scrotal swelling and edema.
COMPARISON: Outside hospital CT dated ___.
TECHNIQUE: CT of the pelvis was performed without intravenous contrast.
Multiplanar reformatted images were reviewed.
FINDINGS:
Extensive subcutaneous edema is seen in the anterior pelvic subcutaneous fat
with skin thickening and edema of the pannus. This edema extends into the
scrotum and is very severe. There are very large bilateral hydroceles. No
subcutaneous gas is detected. The urinary bladder and imaged colon contain
contrast material. No other acute abnormalities are detected in the imaged
portion of the pelvis. Degenerative changes in the lumbar spine are not well
evaluated on this study.
IMPRESSION:
Extensive subcutaneous and scrotal edema and fluid without CT evidence for
subcutaneous gas.
Based on discussion with Dr. ___ by Dr. ___ prior to performing this CT,
the clinical team is aware of these findings and the possibility of early
___ gangrene in the absence of subcutaneous gas.
Radiology Report
HISTORY: Left calf pain.
TECHNIQUE: Grey scale, color and spectral Doppler evaluation was performed on
the left lower extremity veins.
COMPARISON: None
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins.
Normal color flow and compressibility are demonstrated in the posterior tibial
and peroneal veins. There is normal respiratory variation in the common
femoral veins bilaterally.
IMPRESSION:
No evidence of deep vein thrombosis in the left lower extremity.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TESTICULAR SWELLING
Diagnosed with EDEMA, MALE GENITAL ORGN
temperature: 98.9
heartrate: 97.0
resprate: 14.0
o2sat: 97.0
sbp: 144.0
dbp: 77.0
level of pain: 8
level of acuity: 3.0 | ___ h/o morbid obesity, obesity hypoventillation on chronic 02,
not compliant with nocturnal bipap, diastolic CHF, current
resident at ___ since ___ who is transferred from ___ for evaluation of scrotal cellulitis. He does not have
___ gangrene or evidence of necrotizing soft tissue
infection. His obesity, poor skin hygeine, likely diastolic CHF
and pulmonary hypertension, and limited mobility all lead to
accumulation of scrotal edema.
# Scrotal cellulitis: he received: local skin care, scrotal
elevation, IV vancomycin and IV ceftriaxone to cover strep and
MRSA organisms (and some GNR coverage). Urology followed.
Patient did well and was transitioned to Keflex and Bactrim to
end on ___.
He has an inverted penis and Foley catheter will need to remain
in place until a voiding trial is performed at ___. Please
see below for wound care recs. Emphasis is placed on skin care
in the scrotal/inguinal region, and the urethral meatus should
be cleaned daily. The patient is encouraged to walk at least
three times daily. While in the bed or chair, the scrotum
should be elevated to help limit the amount of edema. Tramadol
was used for pain control.
# Chronic hypercarbic respiratory acidosis with metabolic
alkalsosis due to obesity hypoventilation and likely OSA
--SNF notes document non-compliance with nocturnal bipap. He
remained on nocturnal Bipap and 02 titrated to keep sats >88,
below 98%. It is imperative that he continue to receive BiPAP
nightly.
# Diastolic CHF, chronic and pulm hypertension: suspected
--continued PO lasix 100mg weight stable
# Low back rash- resolving dermatitis vs. resolving shingles.
No new lesions, all crusted over. Outside window of benefit
with antiretrovirals, and asymptomatic. Need to continue to
monitor skin for new lesions (no other rash, only in right S2
dermatome in the right gluteal cleft). If new lesions develop,
would consider valacyclovir 1000 mg TID.
# HTN: amlodipine
# Diabetes: continue lantus and SS insulin, held glimiperide and
metformin, and restarted metformin at discharge.
#Hyperlipidemia: simvastatin
#anxiety/depression: fluoxetine
Heparin SC
diabetic diet
Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ludwig's angina
Major Surgical or Invasive Procedure:
___: extra/intraoral I&D of deep neck space
History of Present Illness:
___ is a ___ female with history of poor oral
dentition who presents from OSH with diagnosis of Ludwig's
angina.She has had progressive pain and swelling of her left
face
and neck for the past few days and at OSH was found on CT neck
showed periapical abscess of her remaining left mandibular molar
withsurrounding cellulitis extending into the parapharyngeal
space,and to a lesser extent the retropharyngeal space. She was
transferred on RA, received zosyn at OSH. On presentation
patient
was unable to speak in full sentences and had difficulty
handling
secretions. The decision was made to intubate in the ED to
secure
airway and plan for OR with OMFS for incision and drainage of
deep neck/facial infection.
Past Medical History:
Past Medical History:
HTN, HLD, ?psych history
Past Surgical History:
Left knee replacement
Social History:
___
Family History:
NC
Physical Exam:
Vitals: 102.5 112 177/99
GEN: Intubated, sedated
HEENT: No scleral icterus, mucus membranes moist, L jaw is
markedly swollen that extends to upper neck.
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 100 mg PO QHS:PRN sleep
2. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON
3. timolol maleate 5 mg oral DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
6. Verapamil 160 mg PO Q8H
7. LORazepam 1 mg PO QHS:PRN sleep
8. Atorvastatin 20 mg PO QPM
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
10. Topiramate (Topamax) 200 mg PO BID
11. Cyproheptadine 4 mg PO Q8H:PRN headache
12. Gabapentin 300 mg PO TID
13. Amitriptyline 50 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: switching to PO
Do not exceed 4000 mg daily.
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*20 Tablet Refills:*0
3. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *hydromorphone 4 mg 1 tablet(s) by mouth Q3H Disp #*30 Tablet
Refills:*0
4. Ibuprofen 400-800 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
5. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
6. Amitriptyline 50 mg PO QHS
7. Atorvastatin 20 mg PO QPM
8. Clonidine Patch 0.1 mg/24 hr 1 PTCH TD QMON
9. Cyproheptadine 4 mg PO Q8H:PRN headache
10. Gabapentin 300 mg PO TID
11. LORazepam 1 mg PO QHS:PRN sleep
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. timolol maleate 5 mg oral DAILY
14. Topiramate (Topamax) 200 mg PO BID
15. TraZODone 100 mg PO QHS:PRN sleep
16. Verapamil 160 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
Ludwig's angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with intubated, eval tube position// intubated, eval tube
position
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
Endotracheal tube tip is 5.3 cm from the carina. Enteric tube passes below
the field of view. Lung volumes are relatively low. There is no confluent
consolidation. Probable retrocardiac atelectasis. No large effusion.
Cardiomediastinal silhouette is within normal limits. Old healed right
posterior fourth and fifth rib fractures are noted.
IMPRESSION:
Endotracheal tube tip is 5.3 cm from the carina.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman w/ Ludwig's angina s/p drainage w/ OMFS still
intubated for airway protection// location of ETT/OGT location of ETT/OGT
IMPRESSION:
Compared to chest radiographs ___.
Lungs clear. Heart size normal. No pleural abnormality. ET tube in standard
placement. Nasogastric tube ends in the stomach.
Radiology Report
EXAMINATION: Chest AP view.
INDICATION: ___ year old woman with tooth abscess tracking to neck s/p
drainage by OMFS, now with wheezing, soft BP// ? infiltrates
TECHNIQUE: Chest AP view
COMPARISON: ___ n
IMPRESSION:
The ET tube, NG tube have been removed in the interim. Lungs are low volume
with bibasilar atelectasis. Cardiomediastinal silhouette is unremarkable.
There is no pleural effusion. No pneumothorax is see
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Transfer
Diagnosed with Cellulitis and abscess of mouth
temperature: 102.1
heartrate: 99.0
resprate: 16.0
o2sat: 97.0
sbp: 190.0
dbp: 99.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ presented to ___ ED on ___ with Ludwig's
angina. She was intubated in the ED for respiratory distress and
secretions. She was taken emergently to the operating room on
___ by OMFS. Please see OP Note for more details regarding
the procedure. Patient was kept intubated for 1 days and was
successfully extubated on POD1. She was kept on Unasyn until
___ when she was transitioned to PO Augmentin.
___ drains were removed on ___. She was discharged home
on ___. At the time of discharge, she was tolerating a
regular diet, ambulating independently, voiding spontaneously,
and pain was well-controlled with oral medications. She was
discharged with instructions to follow up in clinic with ___
next ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / lisinopril
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with extensive stage small
cell lung cancer currently on carboplatin and etoposide +
radiation who is admitted from the ED with profound weakness and
dyspnea.
Patient reports approximately two days of progressive weakness
and tremulousness. Her weaekness progressed to the point she
couldn't stand up without assistance, and felt like a 'piece of
spaghetti'. Additionally, when attempting to stand her entire
body would shake with tremors. She notes mild associated
dyspnea.
She has a chronic cough occasionally associated with white
sputum
and has some throat discomfort and odynophagia with radiation.
Her appetite has been very poor. She has no other focal
complaints. No headaches. No visual changes (chronic left eye
blurriness). She has no recent URTI symtpoms. No CP. No N/V or
abodminal pain. She has intermittent constipation, last BM was
yesterday. No dysuria. No myalgias. No leg pain or swelling. No
new rashes.
Patient was seen in radiation oncology today for fraction ___
of planned 3500 cGy. There she was noted to be very weak and
tremulous and requiring assistance with ambulation. She was
transported to the ED.
In the ED, initial VS were pain 0, T 98.6, HR 88, BP 148/49, RR
18, O2 99%RA. Initial labs were notable for Na 134, K 6.2
(hemolyzed, repeat 5.3 whole blood 5.3), HCO3 20, Cr 1.5, Ca
9.0,
Mg 2.2, P 4.3, WBC 7.1, HCT 26.2, PLT 176, UA negative. Rapid
flu
swab negative. CXR showed no evidence of pneumonia and interval
improvement in known RUL mass. Patient was given normal saline
and po lorazepam. VS prior to transfer were T 98.3, HR 79, BP
134/61, RR 16, O2 100%RA.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Ms. ___ is a ___ yrs. female who has a remote history of
cigarette smoking, quit about ___ years ago and a long-standing
history of emphysema. She presented with persistent dry cough
since about 2 months ago and began to developed blood tinged
sputum in mid ___. She has noticed some increased
shortness of breath. She has been on Advair for emphysema which
was no longer helpful. She has more dyspnea especially when she
lies down. She has lost her appetite and lost about 15 pounds
over several months. Due to these complaints, she underwent the
following workup:
___: CXR - 1. Soft tissue opacity right hilar region. Focal
opacity superior segment right lower lobe which may represent
infiltrate, pneumonia or lung lesion. Follow-up contrast
enhanced
CT scan of the chest is recommended to exclude malignancy.
___: CT of chest - 1. Large right upper lobe mass and a
small mass superior segment right lower lobe.
2. Bulky right hilar/suprahilar mass. Subcarinal adenopathy.
Pretracheal adenopathy.
3. Bilateral thyroid nodules. Correlate with nonemergent thyroid
ultrasound. Findings are highly suspicious for malignancy.
Tissue
sampling and PET CT advised.
___: PET/CT -
1. FDG avid right perihilar mass measuring up to 7 cm
demonstrates a max SUV of 23.56, suspicious for primary lung
neoplasm. There is compression upon the bronchus to the
posterior segment of the right upper lobe and probable
associated
atelectasis of the right upper lobe.
2. FDG avid subcarinal lymphadenopathy, FDG avid right axillary
lymphadenopathy, and a FDG avid 1.5 cm lung nodule in the right
lower lobe with max SUVs of 11.33, 13.67, and 13.93,
respectively, likely representing metastatic disease. FDG avid
epicardial lymph node with a max SUV of 3.69, likely
representing
metastatic disease.
3. FDG avid left cervical chain level IV lymph node with a max
SUV of 6.01, likely representing metastatic disease.
4. Two FDG avid subcutaneous soft tissue nodules in the left
posterior upper back superficial to the deltoid muscle and left
gluteal region superficial to the gluteus maximus muscle with
max
SUVs of 20.22 and 15.41, respectively, likely representing
metastatic disease.
- ___: bronchoscopy, EBUS FNA positive for small cell lung
cancer of level 7, 10R, 11R lymph nodes.
- ___ - ___: C1 carboplatin and etoposide.
- ___: seen by Dr. ___ recommends adding radiation
after 2 cycles of chemotherapy.
- ___: C2D1 carboplatin and etoposide.
- ___: starting concurrent XRT, Dr. ___.
- ___: C3D1 carboplatin and etoposide.
- ___: C4D1 carboplatin and etoposide.
PAST MEDICAL HISTORY:
- Latent TB s/p treatment
- CAD s/p LAD stent in ___
- Paroxysmal Afib on ASA, atrial tachycardia
- PVD
- DM
- Hypertension
- Hyperlipidemia
- CKD Stage IV
- COPD
- HLD
- Basal Cell Carcinoma
Social History:
___
Family History:
Her mother and sister died of lung cancer. Her father had
prostate cancer. And one brother had stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.2 HR 84 BP 121/79 RR 22 SAT 100% O2 on RA
GENERAL: Fatigued elderly woman sitting up in bed
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: MMM, Oropharynx clear without lesion, JVD not appreciated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears mildly tachypneic and speakinig in short
sentences, soft inspiratory wheeze throughout. Fair air movement
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; prominent ventral hernia;
no hepatomegaly, no splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Decreased bulk.
NEURO: Alert, oriented, CN III-XII intact, Bilateral ___ strength
is ___ throughout. After exertion she developed rhythmic
fasiculations at about 3Hz in her RLE that persisted for several
minutes. Similar but less pronounced tremeors in LLE.
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 823)
Temp: 98.5 (Tm 98.5), BP: 127/48 (112-135/48-59), HR: 84
(74-84), RR: 17 (___), O2 sat: 99% (97-100), O2 delivery: RA,
Wt: 100.8 lb/45.72 kg
GEN: laying in bed comfortably
HEENT: healing rash in V1 distribution, no further vesicles
CV: NR, RR. Nl S1, S2. No m/r/g.
CHEST: CTAB, redness over chest and back largely resolved
GI: Soft, nontender.
NEURO: Alert, oriented.
Pertinent Results:
ADMISSION LABS
==============
___ 06:00PM BLOOD WBC-7.1 RBC-3.02* Hgb-8.4* Hct-26.2*
MCV-87 MCH-27.8 MCHC-32.1 RDW-20.2* RDWSD-62.9* Plt ___
___ 06:00PM BLOOD Neuts-86.1* Lymphs-8.4* Monos-3.2*
Eos-1.1 Baso-0.6 Im ___ AbsNeut-6.13* AbsLymp-0.60*
AbsMono-0.23 AbsEos-0.08 AbsBaso-0.04
___ 06:50AM BLOOD ___ PTT-22.8* ___
___ 06:00PM BLOOD Glucose-95 UreaN-43* Creat-1.5* Na-134*
K-6.2* Cl-100 HCO3-20* AnGap-14
___ 06:50AM BLOOD ALT-<5 AST-11 LD(LDH)-125 CK(CPK)-18*
AlkPhos-69 TotBili-0.2
___ 06:00PM BLOOD Calcium-9.0 Phos-4.3 Mg-2.2
___ 06:50AM BLOOD ___ 06:50AM BLOOD TSH-1.1
___ 06:50AM BLOOD Cortsol-21.1*
DISCHARGE LABS
==============
___ 06:18AM BLOOD WBC-5.3 RBC-3.08* Hgb-8.8* Hct-26.6*
MCV-86 MCH-28.6 MCHC-33.1 RDW-17.5* RDWSD-55.2* Plt Ct-83*
___ 06:18AM BLOOD Neuts-85* Lymphs-6* Monos-4* Eos-5 Baso-0
AbsNeut-4.51 AbsLymp-0.32* AbsMono-0.21 AbsEos-0.27
AbsBaso-0.00*
___ 06:18AM BLOOD Plt Smr-LOW* Plt Ct-83*
STUDIES
=======
___ CXR: No radiographic findings to suggest pneumonia.
Interval decrease in size of right upper lobe lung mass
compatible with known malignancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
2. aMILoride 5 mg PO DAILY
3. Amiodarone 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Senna 8.6 mg PO BID
10. Torsemide 20 mg PO QAM
11. Torsemide 10 mg PO QPM
12. Vitamin D ___ UNIT PO DAILY
13. Lactulose 30 mL PO Q6H:PRN constipation
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. Glargine 12 Units Bedtime
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 14
Days
DO NOT APPLY TO FACE
3. Sarna Lotion 1 Appl TP TID:PRN pruritis
4. ValACYclovir 1000 mg PO DAILY Duration: 9 Days
5. Glargine 12 Units Bedtime
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
7. aMILoride 5 mg PO DAILY
8. Amiodarone 100 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Lactulose 30 mL PO Q6H:PRN constipation
12. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
13. LORazepam 0.5 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
16. Senna 8.6 mg PO BID
17. Torsemide 20 mg PO QAM
18. Torsemide 10 mg PO QPM
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Localized Herpes Zoster
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with sob// pna
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ and head CT ___
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are unchanged with
dense atherosclerotic calcifications again noted at the aortic knob. The
pulmonary vasculature is normal. Ill-defined focal opacification in the right
upper lobe corresponds to the the patient's known malignancy, grossly
decreased in size and extent when compared to the scout image from the PET-CT.
Remainder of the lungs are clear. No pleural effusion or pneumothorax is
seen. There are no acute osseous abnormalities.
IMPRESSION:
No radiographic findings to suggest pneumonia. Interval decrease in size of
right upper lobe lung mass compatible with known malignancy.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Weakness
Diagnosed with Weakness
temperature: 98.6
heartrate: 88.0
resprate: 18.0
o2sat: 99.0
sbp: 148.0
dbp: 49.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ year-old woman with extensive stage small
cell lung cancer on carboplatin and etoposide with concurrent
radiation who presented from Radiation Oncology with weakness
and dyspnea, most likely I/s/o chemoradiation, subsequently
found to have Herpes Zoster.
# Herpes Zoster
While inpatient, developed pain of L forehead, and subsequent
vesicles in V1 distribution. Slight redness and pruritis of
chest and back. ID & Derm consulted and felt these represented
radiation changes and not disseminated zoster. Started
valacyclovir for planned 14 day course given immunosuppression
(through ___. Consulted ophthalmology for evaluation given V1
distribution and complaint of fuzzy vision in L eye; no evidence
of zoster retinitis, and normal visual acuity, however noted
incidental lesion as below.
# Subretinal Lesion
___ disk-diameter subretinal lesion noted at 5 o'clock next to L
optic nerve during ophthalmologic evaluation which was thought
consistent with choroidal metastasis v. granuloma v. other
inflammatory lesion. Recommended neuroimaging if possible with
thin orbital cuts with contrast; however, given patient is
declining recommended follow-up with Atrius ophthalmology within
1 week of discharge with OCT, visual field and ultrasound.
# Weakness
# Debility
# Tremor
Presented with weakness I/s/o chemoradiation. Infectious
findings negative apart from VZV as above. Intention tremor
noted which has been present for some time. TSH & cortisol
normal. Patient declined all CNS imaging. Evaluated by ___ and
deemed to be below baseline, but likely primarily due to
fatigue; recommended home with home ___ but patient declined home
services.
CHRONIC ISSUES
==============
# COPD
Dyspnea likely due to known COPD. Improved with standing duonebs
and continuation of home inhalers.
# Extensive-Stage SCLC
Followed by Dr. ___ at ___. Currently on treatment break after
3 cycles and conclusion of radiation; will repeat PET in 1
month.
>30 min were spent in discharge coordination and counseling
TRANSITIONAL ISSUES
===================
[ ] Needs ophthalmology f/u within 1 week of discharge to
evaluate heaped-up lesion near L optic disk.
[ ] Should continue valacyclovir for 14 day total course
(through ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
ibuprofen / tramadol / Gadavist / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
chest pain s/p assault
Major Surgical or Invasive Procedure:
1. pigtail chest tube placement
History of Present Illness:
Ms ___ is a ___, PMH significant for obesity s/p RNYGB,
depression, abuse, presented to ___ today after an assault
by her boyfriend. Patient relays that she was shoved by her
assailant, causing her to land on the railroad track. There were
no head strikes or loss of consciousness. She was brought to
___ where she was found to have right sided chest right
fractures with associated pneumothorax. Symptoms are as expected
with pleuretic chest pain, without dyspnea at first. She
therefore declined placement of chest tube despite the
moderately sized pneumothorax. Patient was subsequently
transferred to ___ for trauma evaluation.
In the ED, she reports increasing pain as well as increased
difficulty breathing. A pigtail was placed on the right side
with re-expansion of her lungs on repeat chest XR. Currently she
has
complaints of pain with deep breaths, chronic history of right
shoulder pain (due to abuse), osteoarthritis in her thumbs
bilaterally. Aside from her various chronic pains, she reports
noother acute issues.
Past Medical History:
PMH:
9 SUICIDE ATTEMPTS
ANEMIA
ANXIETY
DEPRESSION
ATTENTION DEFICIT DISORDER WITH HYPERACTIVITY
RIGHT KNEE PAIN
CARPAL TUNNEL TENDONITIS
HEAD TRAUMA (CAR ACCIDENT ___
PSH:
GASTRIC BYPASS ___
KNEE SURGERY ___
right knee
OVARIAN CYSTECTOMY
HIP DYSPLASIA ___
Social History:
___
Family History:
FH:Father-living , rheumatic heart disease, arthritis,
___ heart disease and stroke
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R. Site of previous R
chest tube with dressing c/d/i.
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 05:20AM BLOOD WBC-11.0* RBC-3.99 Hgb-10.7* Hct-36.1
MCV-91# MCH-26.8# MCHC-29.6* RDW-24.5* RDWSD-76.9* Plt ___
___ 05:15AM BLOOD WBC-7.7 RBC-3.74* Hgb-10.3* Hct-33.4*
MCV-89 MCH-27.5 MCHC-30.8* RDW-23.9* RDWSD-74.4* Plt ___
CXR (___): No evidence of substantial pneumothorax after
interval placement of right
pigtail drain.
CXR ___ am): 1. The right pigtail catheter has changed in
position, and some of the side
ports are now external to the pleural space. Associated
accumulation of a
small right pleural effusion and worsening right lower lobe
atelectasis.
2. Minimal subcutaneous emphysema of the soft tissues overlying
the lateral
right seventh and eighth rib fractures.
CXR ___ pm):Comparison to ___, 10:23. The drained
pleural effusion on the right
has further decreased in extent. There is no evidence for the
presence of a
right pneumothorax. Stable appearance of the heart and of the
left lung.
CXR (___): Comparison to ___. The right pigtail
catheter is in unchanged
position. There is no evidence for the presence of a right
pneumothorax. The
right pleural effusion has not Re occurred. Stable normal
appearance of the
cardiac silhouette and of the left lung.
CXR ___ comparison with the study of ___, with the
chest tube on water seal,
there is no evidence of pneumothorax. Mild opacification at the
right base
laterally is essentially unchanged. The remainder the study is
stable.
CXR (___) Cardiomediastinal silhouette is within normal limits.
No pneumothoraces are
seen. There is likely a small right-sided pleural effusion and
there is some
increased soft tissue density, likely related to the prior
pleural catheter
entry site. There is no overt pulmonary edema.
Medications on Admission:
ASA 81'
Effexor XR 300'
atorvastatin 40'
gabapentin 800''''
isosorbide mononitrate ER 30 PRN
metoprolol succinate ER 100'
nitroglycerin 0.3 PRN
omeprazole 40''
trazodone 50 PRN
alprazolam 0.25 PRN
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
Hold if loose stools
2. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
Do not combine with other narcotics or alcohol. Do not drive
while taking
RX *oxycodone [___] 5 mg 2 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Gabapentin 800 mg PO QID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. LORazepam 0.25 mg PO QHS:PRN insomnia
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
10. Omeprazole 40 mg PO BID
11. TraZODone 50 mg PO QHS:PRN insmonia
12. Venlafaxine XR 300 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. right pneumothorax
2. right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with ptx with pig tail; please do standing
expiratory film // interval change
TECHNIQUE: Chest PA and lateral
COMPARISON:
___ chest radiograph
FINDINGS:
In comparison to ___ chest radiograph, there is a new small right
pleural effusion obscuring the right hemidiaphragm. Additionally, the right
pigtail catheter appears to have changed position; some of the side ports are
now external to pleural surface resulting in accumulation of the right pleural
fluid. There is also interval worsening of the right lower lung atelectasis.
The left lung is well-expanded and clear. The right lateral seventh and eighth
rib minimally displaced fractures are again seen; there is mild subcutaneous
emphysema of the overlying soft tissue. The cardiomediastinal and hilar
contours are stable. There is no pulmonary edema or pneumothorax.
IMPRESSION:
1. The right pigtail catheter has changed in position, and some of the side
ports are now external to the pleural space. Associated accumulation of a
small right pleural effusion and worsening right lower lobe atelectasis.
2. Minimal subcutaneous emphysema of the soft tissues overlying the lateral
right seventh and eighth rib fractures.
RECOMMENDATION(S): Discussed findings with ___ at 11:45 via
telephone conversation (___). The impression and recommendation above was
entered by Dr. ___ on ___ at 11:47 into the Department of
Radiology critical communications system for direct communication to the
referring provider.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ s/p assault with right PTX, prior pigtail malpositioned, now
s/p removal and placement of new pigtail // ? position of new tube and ? PTX
? position of new tube and ? PTX
IMPRESSION:
Comparison to ___, 10:23. The drained pleural effusion on the right
has further decreased in extent. There is no evidence for the presence of a
right pneumothorax. Stable appearance of the heart and of the left lung.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with R PTX s/p re-placement of pigtail
yesterday // placement of pigtail,status of PTX placement of
pigtail,status of PTX
IMPRESSION:
Comparison to ___. The right pigtail catheter is in unchanged
position. There is no evidence for the presence of a right pneumothorax. The
right pleural effusion has not Re occurred. Stable normal appearance of the
cardiac silhouette and of the left lung.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with R PTX s/p pigtail placement on water seal
// please eval for resolution of PTX please eval for resolution of PTX
IMPRESSION:
In comparison with the study of ___, with the chest tube on water seal,
there is no evidence of pneumothorax. Mild opacification at the right base
laterally is essentially unchanged.
The remainder the study is stable.
Radiology Report
INDICATION: ___ year old woman with R ptx s/p pigtail placed 3 days ago //
please eval for resolution R PTX, pleural effusion
COMPARISON: Radiographs from ___.
IMPRESSION:
There is a right basilar pigtail catheter. There is a tiny pleural effusion
versus scarring which is unchanged. Lungs are grossly clear. Heart size is
within normal limits. No pneumothoraces are seen. There are no
pneumothoraces.
Radiology Report
INDICATION: ___ year old woman with R ptx s/p pigtail placed 3 days ago //
please eval for resolution PTX, pleural effusion
COMPARISON: Radiographs from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. No pneumothoraces are
seen. There is likely a small right-sided pleural effusion and there is some
increased soft tissue density, likely related to the prior pleural catheter
entry site. There is no overt pulmonary edema.
Radiology Report
INDICATION: ___ year old woman with rib fx s/p pigtail removal for ptx //
Assess for pneumo/hemothorax
COMPARISON: Radiographs from ___
IMPRESSION:
The right basilar pigtail catheter has been removed. No pneumothoraces are
seen. Heart size is within normal limits. Lungs are clear without focal
consolidation or overt pulmonary edema There is some increase soft tissue
density at the right costophrenic angle at the insertion of the previous
pleural catheter.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Assault, Pneumothorax
Diagnosed with Traumatic pneumothorax, initial encounter, Asslt by strike agnst or bumped into by another person, init
temperature: 97.8
heartrate: 87.0
resprate: 16.0
o2sat: 98.0
sbp: 148.0
dbp: 75.0
level of pain: 8
level of acuity: 2.0 | The patient was admitted to our trauma surgery service after
being transferred from an outside hospital for management of a
right pneumothorax s/p assault. CXR also showed associated right
pleural effusion. She had a pigtail catheter placed in the
emergency room that was then replaced the following day when it
was noted to have migrated into an incorrect position on chest
X-ray. Subsequently, daily chest radiographs showed resolution
of her pneumothorax, so her chest tube was transitioned from
suction to water seal. However, her chest tube output remained
high, suggesting persistent pleural effusion so her chest tube
was kept to water seal until this output decreased to
<100cc/day, when the chest tube was pulled and post-pull X-ray
showed no recurrent pneumothorax. Her respiratory status
remained stable throughout her stay and her pain control regimen
was optimized prior to discharge. allowing for adequate
respiratory effort with use of incentive spirometry. She was
discharged home in stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Epinephrine / Xylocaine / Novocaine / Ampicillin / aspirin
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Colonoscopy
Video capsule endoscopy
History of Present Illness:
Ms. ___ is a ___ with history of myeloproliferative disorder,
cerebrovascular accident x2 (___), esophageal varices
complicated by remote gastrointestinal bleed with splenorenal
shunt status post splenectomy, gastritis, and L1 fracture (___)
who presents with subjective weakness. She was in her usual
state of health until approximately 4 weeks prior to admission,
when she developed subjective generalized weakness and fatigue,
which she attributed, at least in part, to continued recovery
from recent L1 fracture, with progression over that period.
Although she is not bedbound, she ambulates minimally around the
house and rarely leaves. She is not limited by lightheadedness,
chest pain, dyspnea on exertion, or low back pain (reports
well-controlled and weaned from TLSO brace to lumbar corset),
but rather by fatigue. She has no difficulty brushing her hair
or rising from a chair without support, though she does require
a walker for assistance with ambulation. Over the same period,
she notes persistent loose stools, consistent in frequency with
baseline attributable to irritable bowel syndrome; she does
endorse occasionally grossly bloody stools due to hemorrhoids,
as well as rarely melanotic stools less than once a month. She
denies bleeding from any other orifice. Her appetite has been
poor in general, and she recalls a few-pound unintentional
weight loss over an uncertain period (weeks), though her
appetite is robust at this moment. Ultimately persuaded by her
family, she notes that she was reluctant to see her primary care
provider until the day prior to admission, when urinalysis/urine
culture were positive for E. coli at ___.
Despite 3 doses of nitrofurantoin, she remains weaker than
expected. She denies fevers/chills, abdominal pain, or
dysuria/hematuria.
In the ED, initial vital signs were as follows: 99.0 91 149/66
20 98%. Admission labs were notable for white blood cell count
of 14 (variable baseline leukocytosis), hematocrit of 26 (down
from recent value of 30, but variable baseline), platelets of
100 (up from ___ at baseline), INR of 2.4 (on Coumadin), and
negative urinalysis. Stool was guiac-positive. 2 large-bore
peripheral intravenous lines were placed. The gastroenterology
service was consulted, with colonoscopy and/or video capsule
endoscopy planned. On transfer, vital signs were: 98.4 80 151/78
18 95%. On arrival to the floor, patient reports extreme hunger,
but she is otherwise comfortable.
Past Medical History:
Myeloproliferative disorder (polycythemia ___ and/or essential
thrombocythemia)
Hypertension
Cerebrovascular accident x2 (___)
Remote gastrointestinal bleed secondary to esophageal varices
complicated by splenorenal shunt status post splenectomy
Bilateral total knee replacement
Osteoarthritis
L1 fracture in ___
Social History:
___
Family History:
Hypertension in multiple family members. Half-brother diagnosed
with leukemia at advanced age.
Physical Exam:
On admission:
VS: 98.9, 148/68, 78, 18, 96% RA
Weight: 55kg
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclerae pale, but anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
BACK no CVAT or spinous/paraspinous tenderness
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, strength ___ throughout, sensation grossly
intact throughout
SKIN notable pallor, no ulcers or lesions
At discharge:
VS: AF/98.8, 148/62 (130s-160s/60s-70s), 82 (70s-80s), 18
(___), 97% (97-98% RA)
Orthostatic VS 110/50 -> 100/48 -> 104/46
GEN Alert, oriented, anxious-appearing in NAD
HEENT MMM EOMI sclerae pale, but anicteric, OP clear
NECK supple, no JVD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
BACK no CVAT or spinous/paraspinous tenderness
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, strength ___ throughout, sensation grossly
intact throughout
SKIN notable pallor, no ulcers or lesions
Pertinent Results:
On admission:
___ 12:48PM BLOOD WBC-14.0*# RBC-3.71* Hgb-7.0* Hct-26.0*
MCV-70*# MCH-18.8*# MCHC-26.9* RDW-21.5* Plt ___
___ 12:48PM BLOOD Neuts-66 Bands-0 ___ Monos-1*
Eos-6* Baso-0 ___ Myelos-0 NRBC-12*
___ 01:30PM BLOOD ___ PTT-39.1* ___
___ 01:30PM BLOOD Glucose-97 UreaN-14 Creat-0.5 Na-139
K-3.6 Cl-106 HCO3-24 AnGap-13
___ 05:50AM BLOOD Albumin-3.0* Calcium-7.6* Phos-3.0 Mg-2.1
Iron-12*
___ 05:50AM BLOOD calTIBC-412 Ferritn-107 TRF-317
___:30PM BLOOD TSH-2.6
___ 01:34PM BLOOD Lactate-1.2
___ 03:01PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:01PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
At discharge:
___ 06:10AM BLOOD WBC-16.7* RBC-3.98* Hgb-7.5* Hct-27.9*
MCV-70* MCH-18.8* MCHC-26.8* RDW-21.4* Plt Ct-63*
___ 06:10AM BLOOD ___ PTT-35.2 ___
___ 06:10AM BLOOD Glucose-85 UreaN-12 Creat-0.6 Na-142
K-4.1 Cl-107 HCO3-27 AnGap-12
___ 06:10AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3
Microbiology:
Blood culture (___) x2: No growth to date
Imaging:
EKG (___):
Sinus rhythm. Left ventricular hypertrophy. Minor ST-T wave
abnormalities.
Since the previous tracing of ___ ventricular premature
beats are no
longer seen and the rate is decreased.
IntervalsAxes
___
___
CXR PA/lateral (___):
Small bilateral pleural effusions, right greater than left.
Subtle opacity at the right lung base is concerning for
pneumonia.
Colonoscopy (___):
Internal hemorrhoids
Linear friability, erythema and petechiae in the distal rectum
compatible with scope trauma
Nonbleeding rectal varix seen in distal rectum
Stool in the whole colon
Foreign body in the sigmoid colon and distal rectum
Diverticulosis of the whole colon
Otherwise normal colonoscopy to cecum
Video capsule endoscopy (___):
Internal hemorrhoids
Linear friability, erythema and petechiae in the distal rectum
compatible with scope trauma
Nonbleeding rectal varix seen in distal rectum
Stool in the whole colon
Foreign body in the sigmoid colon and distal rectum
Diverticulosis of the whole colon
Otherwise normal colonoscopy to cecum
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
Hold for SBP<100
2. Citalopram 10 mg PO DAILY
3. Diazepam 5 mg PO HS:PRN insomnia
4. Losartan Potassium 100 mg PO DAILY
Hold for SBP<100
5. Nitrofurantoin (Macrodantin) 50 mg PO Q6H
6. Peginterferon Alfa-2a 180 mcg SC 1X/WEEK (___)
7. Propranolol 40 mg PO DAILY:PRN palpitations
8. Ranitidine 150 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
11. Warfarin 5 mg PO 5X/WEEK (___)
12. Vitamin D 1000 UNIT PO DAILY
13. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
Hold for SBP<100
2. Citalopram 10 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
Hold for SBP<100
5. Diazepam 5 mg PO HS:PRN insomnia
6. Peginterferon Alfa-2a 180 mcg SC 1X/WEEK (___)
7. Propranolol 20 mg PO DAILY:PRN palpitations
8. Ranitidine 150 mg PO DAILY
9. Simvastatin 20 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Enoxaparin Sodium 80 mg SC DAILY
RX *enoxaparin 80 mg/0.8 mL Please inject 1 80-mg syringe Daily
Disp #*10 Syringe Refills:*0
13. Warfarin 5 mg PO DAILY16
Please take 5mg daily unless directed to change your dose by
your primary care doctor.
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary:
Acute-on-chronic microcytic anemia
Urinary tract infection
Secondary:
Myeloproliferative disorder
History of cerebrovascular accidents
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Weakness, question pneumonia.
FINDINGS: PA and lateral views of the chest were provided. There are clips
again noted in the left upper quadrant. There has been interval development
of a small right pleural effusion with increasing ground-glass opacity at the
right lower lung which could indicate pneumonia. There is mild blunting of
the left CP angle which is stable and may represent a chronic small effusion
or pleural thickening. The heart and mediastinal contours appear stable.
There is no pneumothorax. Bony structures appear intact.
IMPRESSION: Small bilateral pleural effusions, right greater than left.
Subtle opacity at the right lung base is concerning for pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: UTI COMPLAINTS
Diagnosed with ANEMIA NOS, OTHER MALAISE AND FATIGUE, HYPERTENSION NOS
temperature: 99.0
heartrate: 91.0
resprate: 20.0
o2sat: 98.0
sbp: 149.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ with history of myeloproliferative disorder,
cerebrovascular accident x2 (___), esophageal varices
complicated by remote gastrointestinal bleed with splenorenal
shunt status post splenectomy, and L1 fracture (___) who
presented with subjective weakness. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
amoxicillin
Attending: ___.
Chief Complaint:
Patient is an ___ yr old G1 at 24 weeks with fever and flu like
illness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo G1 at 24 weeks 2 days w
mild intermittent asthma who presents with three days of fevers,
chough, and malaise.
She started feeling ill on ___. She progressively became
more fatigued with diffuse myalgias and cough. The patient
reports that she had a fever to 103 on ___, when she
presented
to an outside urgent care facility. There, she was diagnosed
with
a upper respiratory infection and given azithromycin.
She took two doses prior to presentation.
Her symptoms did not improve, and she feels worse today. She
reports decreased appetite, 2 episodes of emesis, and decreased
output of concentrated urine. She also reports cough productive
of scant white sputum, and mild shortness of breath.
Denies contractions, leakage of fluid, vaginal bleeding. Active
fetal movement.
ROS: Denies fevers/chills or recent illness. Denies HA, vision
changes, RUQ/epigastric pain. Denies chest pain, shortness or
breath, palpitations. Denies abd pain. Denies recent falls or
abd trauma. Denies any unusual foods/undercooked foods, nausea,
vomiting, diarrhea.
Past Medical History:
PNC:
- ___ ___ by LMP c/w first tri US
- O + ab neg/ HIV-/ HbSag-/ RI/ RPRNR /GC-/CT-/Trich-
- Varicella immune by hx
- Declined screening
- FFS wnl, LLP
[ ] GLT not yet done
- Issues
*) Low lying placenta on FFS (___)
OBHx:
- G1 current, spontaneous
GynHx:
- regular menses
- No paps
- denies fibroids, endometriosis, ovarian cysts
- denies STIs, including HSV
PMH:
- asthma: one hospitalization in childhood; no intubations
PSH: breast reduction
Social History:
___
Family History:
non contributory
Physical Exam:
On admission:
Physical Exam
___ ___: 116
___ 22:55MSpO2: 100%
___ 18:15Temp.: 101.0°F
___ 16:20MSpO2: 100%
___ 15:25BP: 106/67 (76)
___ 15:24Temp.: 100.1°F
Gen: A&O, comfortable
CV: RRR, no m/r/g
Pulm: nl work of breathing and rate; on initial presentation,
diffuse wheezing per Dr. ___. S/p nebulizer treatment,
lungs are CTAB. Air movement in all lung fields
Abd: soft, gravid, nontender
Ext: no calf tenderness, no edema
On discharge:
Vitals
___ 0411 Temp: 97.7 PO BP: 95/57 HR: 101 RR: 18 O2 sat: 98%
O2 delivery: RA Pain Score: ___
___ 0000 Temp: 98.2 PO BP: 102/64 HR: 109 RR: 20 O2 sat:
97%
O2 delivery: RA Pain Score: ___ Fetal Monitoring: FHR: 145-155
FM: Present
Fluid Balance (last updated ___ @ 414)
Last 8 hours Total cumulative 50ml
IN: Total 1250ml, IV Amt Infused 1250ml
OUT: Total 1200ml, Urine Amt 1200ml
Last 24 hours Total cumulative -792ml
IN: Total 3308ml, PO Amt 1020ml, IV Amt Infused 2288ml
OUT: Total 4100ml, Urine Amt 4100ml
Gen: NAD, speaking in full sentence es
CV: tachycardic to low 100s, regular rate
Resp: no evidence of respiratory distress, CTAB
Abd: soft, gravid, non-tender
Ext: no edema, non-tender
Pertinent Results:
___ 04:10PM BLOOD WBC-7.4 RBC-3.59* Hgb-10.2* Hct-30.5*
MCV-85 MCH-28.4 MCHC-33.4 RDW-12.5 RDWSD-38.4 Plt ___
___ 04:10PM BLOOD Neuts-83.9* Lymphs-6.5* Monos-8.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.22* AbsLymp-0.48*
AbsMono-0.65 AbsEos-0.00* AbsBaso-0.01
___ 06:26AM BLOOD Glucose-83 UreaN-3* Creat-0.3* Na-140
K-3.8 Cl-107 HCO3-22 AnGap-11
___ 09:40AM BLOOD Glucose-101* UreaN-2* Creat-0.4 Na-140
K-3.3* Cl-108 HCO3-22 AnGap-10
___ 04:10PM BLOOD Glucose-91 UreaN-3* Creat-0.4 Na-138
K-3.8 Cl-103 HCO3-21* AnGap-14
___ 4:10 pm URINE Source: ___.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 07:50PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
Medications on Admission:
PNV, albuterol PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4000mg in a day
RX *acetaminophen 500 mg 1 tablet(s) by mouth Q6H PRN Disp #*50
Tablet Refills:*1
2. GuaiFENesin ___ mL PO Q6H:PRN Cough
RX *guaifenesin 100 mg/5 mL 200 mg by mouth Q4H PRN Refills:*2
3. OSELTAMivir 75 mg PO BID Duration: 5 Days
Please continue entire course
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*7
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Influenza A
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old woman, 24 weeks pregnant with cough, fever, asthma//
eval for consolidation/pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Lungs are well expanded and clear. There is no pulmonary edema, pleural
effusion or pneumothorax. Cardiomediastinal silhouette is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: ILI, Pregnant
Diagnosed with Oth pregnancy related conditions, second trimester, Fever, unspecified, Myalgia, unspecified site, Diseases of the resp sys comp pregnancy, second trimester, Other pneumonia, unspecified organism, 24 weeks gestation of pregnancy
temperature: 99.3
heartrate: 115.0
resprate: 20.0
o2sat: 99.0
sbp: 115.0
dbp: 85.0
level of pain: 3
level of acuity: 3.0 | Ms. ___ is a ___ year old G1 with a history of mild
intermittent asthma who was admitted with flu like symptoms and
a positive influenza A culture on ___.
Regarding her influenza A, she presented to triage for history
of three days of fevers and cough. Her Tmax was 103 at home. Her
last febrile episode was 101.2 (___). A WBC returned as
7.4 with 83% neutrophilic left shift. A UA showed large
Leukocytes and ketones and a urine culture was obtained. She had
a rapid flu test which returned positive for Influenza A. A
chest xray was obtained, which returned negative. She received a
IV hydration via a initial 2 liter fluid bolus and was continued
on IV fluids until tolerating PO. She was given acetaminophen 1g
Q6H for fevers and pain and started on Tamiflu 75mg BID for a
planned 5 day course.
She did not continue the azithromycin. In the evening of ___,
patient was tolerating a regular diet. She had normal bladder
and bowel function.
The patient remained afebrile throughout the end of the day on
___ and ___, but did continue to have tachycardia to the
130s. An ECG showed sinus tachycardia on ___. Her tachycardia
improved to the low 100s on ___ with improved po and IV
hydration.
She had good fetal movement and no signs or symptoms of preterm
labor. Her fetal heart tracing was reassuring throughout her
hospital stay.
By hospital day 3, patient was tolerating a regular diet,
ambulating and voiding without issue. She had a sore throat so a
throat swab was sent.This was negative for strep. She was
discharged to home with close follow up on hospital day #3. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / benzocaine
Attending: ___.
Chief Complaint:
sob
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old female with the history below who
presented to the ED today complaining of dyspnea. She reported
3
dd of cough, increased sputum production, URI symptoms, and her
sob became worse last night. In the ED she was found to have
hypoxemia (ra sat high ___. CXR had some ? atypical
infiltrate. She was given azith, pred, neb, and improved. She
was admitted.
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. Patient had a protracted course of pneumonia starting in
___ required two months of antibiotics.
2. Presented to PCP in early ___ with symptoms of
headache,
chest discomfort, right shoulder pain, right arm
weakness/tingling, and difficulty swallowing. A CT scan was
performed on ___ and showed extensive adenopathy,
paratracheal, posterior to the SVC, compressing the SVC, and
enveloping the right main pulmonary artery. There was also
extensive hilar adenopathy, precarinal adenopathy, and
azygoesophageal adenopathy.
3. Patient was subsequently admitted to ___ from ___ to
___. Bronchoscopy with biopsy of level 7 and 4L lymph
nodes
was performed. Note that stenting of right bronchus intermedius
was also performed. Pathology was notable for malignant cells,
consistent with small cell carcinoma. Completion of staging
evaluation revealed no brain or osseous metastases; patient was
considered to have limited stage disease.
4. Cycle 1 of chemotherapy was started on ___ cisplatin 75
mg/m2 on day 1 and etoposide 100 mg/m2 on days ___.
5. Initial visit with radiation oncology on ___. Radiation
was initiated on ___ (31 treatments planned).
6. Patient reported increased tinnitus and hearing loss at visit
on ___. She was evaluated by audiologist (Dr. ___ with
findings notable for high frequency sensorineural hearing loss.
Cycle 2 of cisplatin and etoposide administered on ___
without modification (note that cisplatin administered on day 3
of cycle).
7. Patient subsequently developed chest and upper abdominal
discomfort associated with odynophagia. This was attributed to
GERD with possible contribution from mucositis and she was
started on omeprazole 20 mg QD and magic mouthwash as needed.
8. Patient noted to have new onset right calf swelling on
___. A lower extremity ultrasound was negative for DVT.
9. Bronchial stent was removed on ___.
10. Patient presented to clinic on ___ with chills, sore
throat, shortness of breath, and cough. Patient was admitted to
the hospital for further evaluation and care. CXR was negative
for pneumonia. Blood and urine cultures were negative. Patient
was treated with IVF and sucralfate was added to regimen. She
was discharged home the following day.
11. Cultures from bronchial stent removal returned positive for
stenotrophomonas maltophilia. Patient completed a two week
course of Bactrim (15 mg/kg/day).
12. Cycle 3 of cisplatin and etoposide initiated on ___.
Cycle was complicated by poor PO intake, hypovolemia, and
orthostasis requiring multiple visits to ___
IVF.
13. Follow up audiology evaluation revealed progressive hearing
loss. Carboplatin AUC 6 was substituted for cisplatin in cycle
4
of therapy (administered with etoposide on ___.
14. Radiation therapy end date was ___. Patient received a
total dose of 5580 cGy.
15. Prophylactic cranial irradiation initiated on ___.
PAST MEDICAL HISTORY:
Small cell lung carcinoma
Stage II IDC of breast
Chronic obstructive pulmonary disease
Tobacco abuse
Vertebral degenerative disc disease
Chronic back pain
Scoliosis
Left shoulder bursitis
Osteoporosis
History of pneumonia
Social History:
___
Family History:
2 cousins (1 maternal, 1 paternal) both diagnosed with BC in
___. Mom with Lung ca, Dad throat ___
Physical Exam:
Afebrile and vital signs stable (reviewed - see according
flowsheets and or bedside record); specific comments regarding
VSS
FSBG (if recorded):
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERRL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy, no JVD,
no carotid bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout all
extremities and symmetric. No sensory deficits to light touch
appreciated. No pass-pointing on finger to nose.
2+DTR's-patellar and biceps. No asterixis, no pronator drift,
fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no urinary catheter in place
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
3. Fentora (fentaNYL citrate) 400 mcg buccal Q6H:PRN
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. FoLIC Acid 1 mg PO DAILY
6. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN osb
7. Mirtazapine 7.5 mg PO QHS
8. Morphine SR (MS ___ 60 mg PO Q12H
9. Omeprazole 20 mg PO DAILY
10. Bisacodyl 10 mg PO DAILY:PRN c
11. Multivitamins 1 TAB PO DAILY
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 3 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H sob
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 neb
neb q 6 H Disp #*60 Ampule Refills:*0
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine [Nicoderm CQ] 21 mg/24 hour 1 patch daily Disp #*30
Patch Refills:*0
4. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 10 mg 4 tablets(s) by mouth daily Disp #*12 Dose
Pack Refills:*0
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN Headache
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
7. Bisacodyl 10 mg PO DAILY:PRN c
8. Fentora (fentaNYL citrate) 400 mcg buccal Q6H:PRN
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. FoLIC Acid 1 mg PO DAILY
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN osb
12. Mirtazapine 7.5 mg PO QHS
13. Morphine SR (MS ___ 60 mg PO Q12H
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
AECOPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with sob // PNA? PNA?
IMPRESSION:
Compared to chest radiographs ___.
Mild interstitial abnormality is new, either edema or atypical pneumonia.
There is no consolidation to suggest bacterial pneumonia. Heart size is
normal though increased compared to ___. No pleural effusion.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 98.6
heartrate: 103.0
resprate: 16.0
o2sat: 97.0
sbp: 137.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | AECOPD, likely due to viral URI. Flu neg. Stable. Improved
rapidly with nebs, abx, and prednisone. Ambulatory sats normal
on room air, felt much better by HD 3, evaluated by ___ and felt
safe for home no services from a mobility standpoint.
Encouraged smoking cessation repeatedly to pt. Gave nicoderm
patch
Hx mult cancers, ? in remission, due for surveillance in onc f/u
___. No acute issues on this front evident during this
hospitalization
Chronic back pain on high dose opiates: cont ms contin. We do
not have fentora. Discussed with pharmacy, who recommended
dilaudid po ___ mg q 3 h prn pain while hospitalized, which
worked well for pain control without sedation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Lamictal / Dilantin
Attending: ___.
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old R-handed woman with PMHx of HTN, HL,
possible epilepsy and spinal stenosis who presents with multiple
falls.
Pt reports that starting ___ years ago she began to have
intermittent slurring of her speech (___) and stiffening
of her legs (1x/month) that would always resolve within 10 mins.
She would also occasionally have difficulty with writing "my
handwriting would become chicken scratch", which would also
resolve within 10 mins. These episodes were thought to be
seizures, but she has had multiple LTM admissions (most recently
at ___ in ___ that did not capture any of these events
and did not find any EEG abnormalities. She had an EEG done in
___ in ___ where the "thought they saw some changes
in the temporal lobe". She was initially put on dilantin, but
this gave her a rash and so she was switched to different
medications. She is followed by Dr. ___ here at
___, and in ___, she was referred to Dr. ___
consultation on if the above events could be TIAs. He reviewed
her OSH MRI and determined that both hx and imaging were not c/w
strokes or TIA's. Pt then feel in Novemeber onto her head on
the R side where her glasses broke and lacerated her R forehead.
Pt reports that she felt like she got a "sudden push" from
behind in the middle of her back that propelled her forwards
associated with stiff legs. She was unable to get herself up on
her own, so she had an ambulance come and take her to ___.
___, where a CT head was done that was negative for acute
process. She saw Dr. ___ at the end of ___ and
she was changed from generic keppra to brandname keppra (which
was actually started by the patient in the middle of ___.
She then had some sensation of her legs stiffening in the
beginning of ___, but these were c/w her prior episodes
where it disappeared within 10 mins. She saw Dr. ___
again in early ___ who put her on trileptal with the plan to
uptitrate the trileptal and wean off the keppra. Pt increased
her trileptal dose yesterday from 300mg BID to ___ QAM and
450mg QPM.
.
Yesterday pt woke up feeling fine, got out of bed, ate
breakfast, but then at around 8am was walking into the kitchen
and fell, hitting her L hand and L forehead. She reports that
she had the same sensation of being propelled forwards with
stiff legs as she did in ___. However, the leg stiffness
lasted for 1.5hrs this time. She was able to get over to a
chair and allow it to subside. She reports that she started to
feel mildly nauseated at this time, but did not vomit. She
denies any associated H/A, numbness/tingling, vision
disturbance, difficulty with speech production or comprehension,
weakness, vertigo or any other associated sx at that time. She
then "puttered around the house" and went to make lunch at
around noon and "felt the stiffness coming on" along with a
sensation of feeling off-balance (but not vertiginous), and she
was able to make it to a couch. Again the sensation of stiff
legs lasted for 1.5 hours. She got up after it dissipated and
ate lunch, but then at 6pm when she went to have dinner she felt
the stiffening again and her husband was able to help her get to
the couch. This episode of stiffening lasted 3 hours, but did
eventually go away and she was able to sleep.
.
This morning, she woke up, and got out of bed, but as soon as
she took a few steps away from the bes, she felt both legs
stiffen. She was able to walk over to the couch, where she
stayed until 1:30pm. Her daughter came to visit, and noticed
that when the pt tried to eat soup her arm appeared too stiff to
lift the soup to her mouth. Also, when the daughter tried to
take the spoon out of her mother's hand she had to "pry it out
of her hand", as pt's hand was "clasped" around the spoon. Pt
was also having slurred (but appropriate) and mumbled speech at
this time, that was similar to her prior events of slurred
speech. Pt's husband and daughter felt that the stiffness was
too severe to attempt to get the patient downstairs and into the
car themselves so they called ___ to be taken to the ED. Her sx
had resolved by the time she got to the ED.
.
In the ED, pt's daughter noted that the pt had another episode
of slurred speech, but that this was more subtle and lasted for
only a few mins.
.
On neuro ROS, the pt denies current headache, loss of vision,
blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HTN
- HL
- osteopenia
- spinal stenosis (per pt report)
- above described intermittent episodes of slurred speech, stiff
legs and handwriting difficulties thought to be epilepsy
Social History:
___
Family History:
Her father had coronary artery disease. Her mother had
pancreatic cancer. No neurological history in family, including
no seizure disorders.
Physical Exam:
ADMISSION
Physical Exam:
Vitals: T:98.4 P: 74 R: 16 BP:155/89 SaO2: 97% on 2L NC
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, pt with bruising over L eye and forehead
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally, abrasion on dorsal surface of L hand.
.
Neurologic:
.
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes. The pt. had good knowledge of current events. There
was no evidence of apraxia or neglect.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
.
-Sensory: No deficits to light touch, pinprick, vibratory sense,
proprioception throughout. No extinction to DSS. Pt had
impaired temperature sensation in her proximal R arm, her R leg
and her proximal L leg (felt tuning fork as warm).
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was flexor on the R and extensor on the L.
.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
.
-Gait: Good initiation. Hesistant walk with small steps, but
this gait appeared self-imposed as pt afraid of falling. Able
to walk in tandem for 5 steps without falling. Romberg absent.
Pertinent Results:
___ 03:35PM WBC-5.6 RBC-4.37 HGB-14.2 HCT-39.1 MCV-90
MCH-32.5* MCHC-36.3* RDW-12.7
___ 03:35PM NEUTS-68.5 ___ MONOS-6.1 EOS-0.5
BASOS-1.0
___ 03:35PM PLT COUNT-146*
___ 03:35PM CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-2.1
___ 03:35PM GLUCOSE-127* UREA N-10 CREAT-0.7 SODIUM-131*
POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-26 ANION GAP-13
___ 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 06:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:49PM cTropnT-<0.01
___ CT head
No acute intracranial process
___ C-spine Flex/Ext Xray
There are extensive degenerative changes demonstrated, as well
as diffuse
osteopenia. Alignment is preserved. For precise details, please
review MRI
of the cervical spine obtained the same ___ earlier.
___ MR ___, T, L spine
FINDINGS: Evaluation of the cervical spine demonstrates mild
disc bulges at C4-C5 and C2-C3 without significant compromise of
the canal or
foramina.Bilateral foraminal narrowing is noted at C4-C5 which
is moderate. There is apparent prominence of the posterior
epidural fat.
Evaluation of the thoracolumbar spine demonstrates no
abnormality of marrow signal, vertebral body height, and
alignment. Mild disc bulges are seen at L4-L5 and L5-S1. No
evidence of cord signal abnormality or cord compression.
Bilateral facet DJD at L4-L5 and L5-S1. No pathologic
enhancement.
There are apparent prominent veins in the bilateral occipital
lobes. Consider MRI of the brain for further evaluation.
IMPRESSION:
Mild degenerative changes as described. No evidence of
significant canal
compromise or cord compression. No cord signal abnormality.
Apparent prominent veins in the bilateral occipital lobes.
Consider MRI of
the brain for further evaluation.
Medications on Admission:
- Diovan 160mg QD
- keppra XR 500mg Q24hrs
- fish oil QD
- vitamin D3 1,000 units QD
- ASA 81mg QD
- verapamil 360mg QD
- HCTZ 12.5mg QD
- alendronate 70mg QWeek
- simvastatin 40mg QD
- levothyroxine 125mcg QD
- folic acid ___ QD
- trileptal 300mg QAM and 450mg QPM
Discharge Medications:
1. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
2. oxcarbazepine 150 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
3. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Keppra XR 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
8. verapamil 120 mg Tablet Extended Release Sig: Three (3)
Tablet Extended Release PO Q24H (every 24 hours).
9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
1. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
2. oxcarbazepine 150 mg Tablet Sig: Three (3) Tablet PO QPM
(once a day (in the evening)).
3. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Keppra XR 500 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
8. verapamil 120 mg Tablet Extended Release Sig: Three (3)
Tablet Extended Release PO Q24H (every 24 hours).
9. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
once a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Outpatient Physical Therapy
As per ___
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical Spondylosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with weakness and trauma, rule out pneumonia.
COMPARISON: No relevant comparisons available.
TWO VIEWS OF THE CHEST:
The lungs are low in volume but clear. The cardiac silhouette is top normal.
The mediastinal silhouette and hilar contours are normal. An opacity in the
right lower lobe likely represents summation of structures related to the
ribs.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
INDICATION: ___ female with weakness, trauma, rule out pneumonia,
rule out intracranial hemorrhage.
COMPARISON: No relevant comparisons available.
TECHNIQUE: MDCT images were acquired through the head without contrast.
Standard soft tissue algorithms, bone algorithms and multiplanar reformations
were obtained and reviewed.
FINDINGS: There are small bilateral basal ganglia punctate areas of
hyperattenuation consistent with calcifications. No acute intracranial
hemorrhage, large vascular territory infarct, shift of midline structures or
mass effect is present. Mild hypoattenuation of the bihemispheric
periventricular white matter is consistent with sequalae of small vessel
ischemic disease. The ventricles and sulci are mildly prominent consistent
with age-related atrophy. The visible paranasal sinuses and mastoid air cells
are well aerated.
IMPRESSION: No acute intracranial process.
Radiology Report
REASON FOR EXAMINATION: Recurrent fall.
AP, lateral, and flexion position of the cervical spine were reviewed.
There are extensive degenerative changes demonstrated, as well as diffuse
osteopenia. Alignment is preserved. For precise details, please review MRI
of the cervical spine obtained the same day earlier.
Radiology Report
TECHNIQUE: MRI of the complete spine without and with gad.
HISTORY: Falls and stiffening, assess for acute process.
COMPARISON: None.
FINDINGS: Evaluation of the cervical spine demonstrates mild disc bulges at
C4-C5 and C2-C3 without significant compromise of the canal or
foramina.Bilateral foraminal narrowing is noted at C4-C5 which is moderate.
There is apparent prominence of the posterior epidural fat.
Evaluation of the thoracolumbar spine demonstrates no abnormality of marrow
signal, vertebral body height, and alignment. Mild disc bulges are seen at
L4-L5 and L5-S1. No evidence of cord signal abnormality or cord compression.
Bilateral facet DJD at L4-L5 and L5-S1. No pathologic enhancement.
There are apparent prominent veins in the bilateral occipital lobes. Consider
MRI of the brain for further evaluation.
IMPRESSION:
Mild degenerative changes as described. No evidence of significant canal
compromise or cord compression. No cord signal abnormality.
Apparent prominent veins in the bilateral occipital lobes. Consider MRI of
the brain for further evaluation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with OTHER MALAISE AND FATIGUE, HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, CHEST PAIN NOS
temperature: 98.4
heartrate: 74.0
resprate: 16.0
o2sat: 97.0
sbp: 155.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | ___ h/o HTN, HL, recurrent falls p/w similar episodes of
recurrent falls with leg stiffening, being "propelled forwards",
and occasionally mild slurring of speech without any impairment
of consciousness.
[] Falls - The patient has signs of myelopathy on examination
with weakness and brisk reflexes but no significant sensory
changes. She has cervical spinal canal stenosis on MRI. This is
most consistent with cervical spondylosis with myelopathy. She
was treated with a soft cervical collar. A spine consult was
obtained and there was no recommendation for surgical
intervention. She will follow up in the ___ further
management.
[] ? Seizures - She was monitored on 24h cvEEG monitoring and
had several typical events without any EEG correlate. She was
advised to taper off her Keppra and Trileptal slowly and to
follow up in the epilepsy clinic for further management.
Physical therapy and occupational therapy evaluated the patient
while admitted and cleared her for discharge home with
outpatient ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
multiple myeloma diagnosed ___ currently undergoing
radiation therapy for L5 plasmacytoma presenting today with
chief complaint of new fevers, chills and body aches (tmax 101.1
on morning of admission) and fatigue. She completed a 2 week
dexamethasone course on ___. She has yet to receive
chemotherapy treatment though feels very anxious and emotional
regarding the prospect of chemotherapy. Overnight she began
feeling feverish with chills and took 2 Tylenol. She again felt
feverish this morning and had a fever to 101.1.
In the ED initial vitals were 100.7 76 107/47 18 98%. Labs were
notable for WBC of 2.7 (83 % PMNs). CXR showed no acute process.
UA was without evidence of UTI. Blood and urine cultures were
sent. The patient was given vancomycin and cefepime and admitted
to OMED for further evaluation.
On the floor the patient appears comfortable. She endorses a
mild ___ frontal headache though denies neck stiffness, light
sensitivity, nausea, vomiting. She denies cough, chest pain, or
shortness of breath. She denies abdominal pain, diarrhea, or
constipation, though her last bowel movement was yesterday. She
denies dysuria, myalgias, chills, or fevers at this time. Her
current back pain is ___ in severity. She notes that this
morning she felt a "shift" in her lower back, but denies current
pain, bowel or bladder incontinence, worsening weakness,
numbness or tingling in her lower extremities.
She denies sick contacts, recent travel, though was in the
hospital on ___ for evaluation of back pain.
Past Medical History:
Onc:
Multiple myeloma without treatment. IgG level os 3196 on
___. IFE shows monoclonal IgG kappa of 38%.
PMHx:
- motor vehicle accident in ___
- endometriosis
- fibroids in her uterus
- benign tumors in the breast removed in her early ___
- hypothyroidism for which she was on a Synthroid, however, it
developed palpitations and stopped the medication on her own.
She states that her PCP has not repeated her thyroid stimulating
hormone levels since she stopped the medication.
- asthma attack in ___. She believes this was related to paint
exposure.
Social History:
___
Family History:
-Brother died at age ___ of an aneurysm in his stomach. He was
also obese.
-Mother died at age ___ of colon cancer.
-Father died at age ___. Had diabetes, myocardial infarction, and
a gangrenous infection.
-Sister who is alive and well with a history of hypothyroid and
hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 98.8 104/42 69 18 94% RA
General: Very pleasant woman, lying in bed in NAD, face mask on
HEENT: Oropharynx clear, moist mucous membranes, no LAD, no
photosensitivity with flashlight, PERRL, scleara anicteric
Neck: Soft, without LAD, no meningismus
CV: Regular rate and normal rhythm, no m/r/g
Lungs: CTAB, no wheezes, rhonchi, crackles
Abdomen: Normoactive BS, no tenderness to palpation, no rebound
or guarding
GU: No foley
Ext: Warm and well perfused, no edema. Point tenderness to
palpation in ASIS bilaterally
Neuro: CN II-XII intact, ___ strength in upper extremities
bilaterally, ___ strength in lower extremities bilaterally,
sensation to light touch intact bilaterally. Straight leg test
negative bilaterally.
DISCHARGE PHYSICAL EXAM
VITALS: Tc 98.0 100/58 62 18 100% RA
GENERAL: Pleasant, NAD, alert, interactive
HEENT: Oropharynx clear, moist mucous membranes, no LAD, no
photosensitivity with flashlight, PERRL, sclerae anicteric
LUNGS: Clear to auscultation, no wheezes, crackles, rhonchi
HEART: Regular rate and normal rhythm, no m/r/g
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP, no edema.
SKIN: Faint isolated erythematous 1-3mm macules on the cheeks
bilaterally, L>R
NEURO: awake, A&Ox3, strength ___ in lower extremities
bilaterally, sensation intact to light touch in ___.
Straight leg test negative bilaterally.
Pertinent Results:
ADMISSION LABS
___ 01:40PM BLOOD WBC-2.7* RBC-3.58* Hgb-11.2* Hct-34.2*
MCV-95 MCH-31.4 MCHC-32.9 RDW-14.1 Plt ___
___ 01:40PM BLOOD Neuts-83.7* Lymphs-6.4* Monos-9.4 Eos-0.3
Baso-0.2
___ 01:40PM BLOOD Plt ___
___ 01:40PM BLOOD Glucose-94 UreaN-10 Creat-0.7 Na-131*
K-5.9* Cl-99 HCO3-23 AnGap-15
___ 01:40PM BLOOD ALT-26 AST-61* AlkPhos-95 TotBili-0.7
___ 01:40PM BLOOD Albumin-3.5 Calcium-8.7 Phos-4.0 Mg-2.2
___ 01:43PM BLOOD Lactate-1.2
DISCHARGE LABS
___ 07:51AM BLOOD WBC-2.4* RBC-3.47* Hgb-11.0* Hct-32.9*
MCV-95 MCH-31.6 MCHC-33.3 RDW-14.0 Plt ___
___ 07:51AM BLOOD Neuts-78.4* Lymphs-15.4* Monos-4.9
Eos-1.1 Baso-0.3
___ 07:51AM BLOOD Plt ___
___ 06:20AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-137
K-3.7 Cl-107 HCO3-22 AnGap-12
___ 06:20AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
CXR ___
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest. Slightly lower lung volumes
seen on the current exam. The lungs however remain clear.
There is no consolidation or effusion. The cardiomediastinal
silhouette is unchanged given differences in technique. No acute
osseous abnormalities detected.
IMPRESSION:
No acute cardiopulmonary process
___:
EBV: Pending
Parvovirus: Pending
CMV DNA: Negative
___: Blood culture x2 No growth to date
___ 3:00 pm URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain
2. Acetaminophen 1000 mg PO Q8H:PRN fever, pain
3. Docusate Sodium 100 mg PO BID
4. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN fever, pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain
4. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Fever and fatigue
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with dyspnea and fevers. History of multiple
myeloma and chemotherapy.
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest. Slightly lower lung volumes seen on the
current exam. The lungs however remain clear. There is no consolidation or
effusion. The cardiomediastinal silhouette is unchanged given differences in
technique. No acute osseous abnormalities detected.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 100.7
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 107.0
dbp: 47.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with a history of
multiple myeloma diagnosed ___ currently undergoing
radiation therapy for L5 plasmacytoma presenting with chief
complaint of fever, chills, and body aches.
Fever: Ms. ___ presented with a fever to 101.2 on the
morning of admission though had no subsequent fevers. The
etiology of her fevers is unclear without localizing source on
history or physical exam. She was afebrile throughout her
hospitalization. She was initially started on Vancomycin and
Cefipime for neutropenic fever. Antibiotics were discontinued on
hospital day #2. She was monitored for 24 hours after
discontinuation of antibiotics without recurrence of fever. She
was not neutropenic during her hospital stay. Urine culture was
negative. Blood cultures revealed no growth. CMV DNA was
negative though EBV and HHV6 results were pending on discharge.
She was counseled on the importance of returning to the hospital
if her fever returns and she expressed understanding.
Plasmacytoma and back/leg pain: Ms. ___ is currently
undergoing radiation therapy for L5 plasmacytoma causing nerve
root compression with palliative radiotherapy to L4-S1. She has
not yet started chemotherapy due to personal hesitation and
anxiety. She received 2 radiation treatments during her hospital
stay and is scheduled for her last fraction on ___. She
ambulated without difficulty during her hospital stay without
change in lower extremity strength, no bowel or bladder
incontinence, and denied lower extremity pain. She will continue
with radiotherapy to L4-S1 as noted above. She will follow up
with Heme/Onc in clinic to further discuss systemic therapy on
___.
Rash: Ms. ___ presented with isolated 1-2 mm
erythematous non-confluent, non-pruritic macules on her cheeks
bilaterally on hospital day #3. Possibly viral vs drug related,
and improved prior to discharge.
FEN: Regular diet, gluten free
Prophylaxis:
DVT prophylaxis with heparin- patient refused heparin during her
hospital stay. Ambulated daily.
Pain: Oxycodone PRN. Avoided Tylenol to assess for fevers.
Bowel regimen: Senna and Colace |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / latex
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with a history of angioedema, known 3 VD (was being
evaluated as outpt for CABG), MI ___ and recent CCU admission
___ for STEMI when she received DES x2 to the LAD, POBA
of LCX and was diagnosed with acute sCHF with 35%EF with
dyspnea.
On her previous admission she presented with CP, diaphoresis and
fatigue; it was noted that she had declined CABG for her known
3V CAD ___ years ago. During her previous admission she declined
numerous treatments including a statin; but eventually agreed to
rosuvastatin once weekly. She was discharged on a BB, ACE, ASA,
ticagrelor and 20mg PO lasix.
The morning of ___ she called the heart line and stated that
since her discharge she was having progressive shortness of
breath and palpitations. She also had difficulty sleeping at
night with orthopnea, but continued to perform ADL's. She
denied chest
discomfort, but endorsed lightheadedness, presyncope and cold
sweats when sitting up at night. It was recommended that that
the patient come to the ED for evaluation however she was not
amenable to this plan and stated that her primarycare physician
makes home visits and that she would call him. He saw her at
home and she still did not want to come in, but later her
dyspnea worsened and eventually she came to the ED the morning
of ___.
On arrival she denied CP, fevers, abd pain, n/v. Initial vitals
were HR 99, T 97.8, 139/83, 80% on RA with a good pleth. She
was put on a non-rebreather and was 96% with a RR of 27, working
hard to breath and put on CPAP at 100% ___ and was satting 100%.
She stated she was DNR/DNI and did not want to be cathed but
wanted everything else done to be comfortable. Exam was
significant for crackles and JVD. EKG showed NSR at 99, inf/lat
STD's. CXR showed bilateral pulmonary edema. Initial labs
showed:
VBG: pH 7.37, CO2 41, pO2 41 lactate of 4.4. Trop 4.5 from 5.07
on ___. Na 141, K 5.4, Cl 103, HCO3 21, BUN 39, Cr 1.2 (from
0.8 on discharge). LFT's WNL. WBC 16.7, HCT 34.4, PLT 507, 88.8%
N. INR 1.2. She was given lasix 40mg IV and started on a nitro
gtt.
Vitals on transfer were HR 89 122/70 RR 25 100% cpap. Sent to
the CCU for CPAP/BiPap and monitoring. ___ was placed prior to
transfer, but she had not yet put out to lasix which she
received approximately 5:00.
On arrival to the CCU she is uncomortable with the cpap mask on,
otherwise has no complaints. She notes that after leaving the
hospital she did not take lasix "because it's too much". She
only took the metoprolol, aspirin, and one other medication.
She noted a cough, not productive. Denied dysuria. One loose
stool yesterday. She thinks her weight is up 2lbs even though
she has not been eating or drinking much.
Past Medical History:
- Myocardial infarction - ___
- Coronary artery disease: 3VD, no cath records available
- Hypertension
- Hyperlipidemia
- GERD
- Anaphylaxis/angioedema: Multiple ED visits/admissions for
anaphylaxis/angioedema without clear precipitant. Left AMA.
- Meniere's disease
- Skin cancer - left forearm
- Adenomatous colon polyps
- Herpes Zoster
- Osteoarthritis and Osteoporosis
- Sciatica
- Spinal stenosis
- Hiatal hernia
- Infected sebaceous cyst
Social History:
___
Family History:
Daughter: allergic to almonds and walnuts
Mother: HTN, "heart attack"
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.8 89 137/79 22 100% on BiPAP
___: tired-appearing woman sitting up in bed BiPAP mask in
place, AOx3
HEENT: head atraumatic; dry MM
Neck: JVP appears 10cm but difficult to evalute with CPAP on
CV: RRR; no m/r/g
Lungs: breathing comfortably; slight crackles at bases
Abdomen: soft; nontender; nondistended; normoactive bowel sounds
GU: foley
Ext: WWP; no edema
Neuro: A and O x3; moving all four extremities
DISCHARGE PHYSICAL EXAM:
========================
VS 98.2 76 115/52 22 96% ___: NAD, AOx3
HEENT: head atraumatic; dry MM
Neck: JVP appears 10cm but difficult to evalute
CV: RRR; no m/r/g
Lungs: breathing comfortably; slight crackles at bases
Abdomen: soft; nontender; nondistended; normoactive bowel sounds
GU: no foley
Ext: WWP; no edema
Neuro: A and O x3; moving all four extremities
Pertinent Results:
ADMISSION LABS:
===============
___ 03:25AM BLOOD WBC-16.7* RBC-3.63* Hgb-10.5* Hct-34.4*
MCV-95 MCH-29.1 MCHC-30.6* RDW-14.9 Plt ___
___ 03:25AM BLOOD Neuts-88.8* Lymphs-5.7* Monos-5.2 Eos-0.2
Baso-0.2
___ 03:25AM BLOOD ___ PTT-22.0* ___
___ 03:25AM BLOOD Glucose-264* UreaN-39* Creat-1.2* Na-141
K-5.4* Cl-103 HCO3-21* AnGap-22*
___ 03:25AM BLOOD ALT-39 AST-37 AlkPhos-79 TotBili-0.5
___ 03:25AM BLOOD cTropnT-4.50*
___ 10:30AM BLOOD CK-MB-7 cTropnT-4.18*
___ 10:30AM BLOOD Albumin-3.0* Calcium-8.4 Phos-4.5# Mg-2.2
___ 03:29AM BLOOD ___ pO2-41* pCO2-41 pH-7.37
calTCO2-25 Base XS--1
___ 03:29AM BLOOD Lactate-4.4*
___ 10:30AM URINE Color-Straw Appear-Clear Sp ___
___ 10:30AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 10:30AM URINE RBC-2 WBC-18* Bacteri-NONE Yeast-NONE
Epi-<1
___ 10:30AM URINE CastHy-8*
___ 10:30AM URINE Mucous-RARE
PERTINENT LABS:
===============
___ 03:29AM BLOOD Lactate-4.4*
___ 11:02AM BLOOD Lactate-2.8*
___ 05:59PM BLOOD Lactate-1.5
___ 03:25AM BLOOD cTropnT-4.50*
___ 10:30AM BLOOD CK-MB-7 cTropnT-4.18*
PERTINENT IMAGING/STUDIES:
==========================
ECG ___:
Sinus rhythm. Biatrial abnormality. Right bundle-branch block
with left
anterior fascicular block. Probable prior anterior wall
myocardial infarction. No major change from the previous
tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 ___ 57 -69 110
CXR ___:
IMPRESSION: Severe pulmonary edema.
CXR ___:
FINDINGS: As compared to the previous radiograph, the pleural
effusions have slightly increased in extent, but the signs
indicative of centralized
pulmonary edema has decreased in severity. The size of the
cardiac silhouette remains enlarged. Atelectasis at both lung
bases, but no evidence of pneumonia. No pneumothorax.
PERTINENT MICRO/CYTOLOGY:
=========================
___ 10:30 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
BCx ___: Pending (NGTD)
DISCHARGE LABS:
===============
___ 05:55AM BLOOD WBC-10.3 RBC-3.61* Hgb-10.3* Hct-33.3*
MCV-92 MCH-28.5 MCHC-30.9* RDW-15.3 Plt ___
___ 05:55AM BLOOD Glucose-110* UreaN-40* Creat-0.9 Na-141
K-4.4 Cl-103 HCO3-28 AnGap-14
___ 05:55AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TiCAGRELOR 90 mg PO BID
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Lorazepam 0.125 mg PO HS:PRN insomnia
4. Aspirin EC 81 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL PRN chest pain
8. Rosuvastatin Calcium 5 mg PO 1X/WEEK (MO)
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Rosuvastatin Calcium 5 mg PO 1X/WEEK (MO)
6. TiCAGRELOR 90 mg PO BID
7. Lorazepam 0.125 mg PO HS:PRN insomnia
8. Nitroglycerin SL 0.4 mg SL PRN chest pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute on chronic systolic heart failure
ST elevation myocardial infarction
Acute Kidney Injury
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath.
COMPARISON: Chest radiograph ___.
FINDINGS:
Single AP view of the chest was reviewed. Cardiomediastinal and hilar
contours are normal. There is no pneumothorax. Dense parenchymal opacities,
especially in the lower lung zones, are consistent with severe pulmonary
edema. There is no large pleural effusion. Displacement of the trachea to the
left may be the result of a goiter in the right lobe of the thyroid.
IMPRESSION:
Severe pulmonary edema.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Lung edema, evaluation for pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the pleural effusions have
slightly increased in extent, but the signs indicative of centralized
pulmonary edema has decreased in severity. The size of the cardiac silhouette
remains enlarged. Atelectasis at both lung bases, but no evidence of
pneumonia. No pneumothorax.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: RESP DISTRESS
Diagnosed with PULM EMBOLISM/INFARCT
temperature: nan
heartrate: 99.0
resprate: nan
o2sat: 92.0
sbp: 139.0
dbp: 83.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ with CAD and known 3VD s/p recent
hospitalization ___ for STEMI who presents with dyspnea,
pulmonary edema and 2 lb weight gain suggestive of decompensated
heart failure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lipitor
Attending: ___
Chief Complaint:
Weight gain, face and leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with past medical history of
T1DM, retinopathy, neuropathy, Charcot foot, ESRD s/p SCD kidney
transplantation in ___, repeated skin cancers related to
immune
suppression, hx of Hep C (undetectable vital load in ___, HTN,
who came to the ED with weight gain, swelling over face and
legs.
Patient was hospitalized recently for upper respiratory tract
infection in ___ with short hospital stay (per
patient). Group home personnel noticed weight increase of ___
lbs
in 5 days with swelling in his face and bilateral lower
extremities. Patient denies SOB, orthopnea, PND, chest pain or
syncope. Patient denies subjective fevers, chills, nausea,
vomiting or abdominal pain.
Of note, patient had kidney biopsy in ___ likely due to
proteinuria. Biopsy results are not back yet.
-In the ED, vitals were: T 98.8; HR 81; BP 142/78; RR 20; SpO2
100% RA
-Exam:
2+ pitting edema symmetric
Diffuse abdominal tenderness most prominent in the right lower
quadrant over multiple evaluations
brown stool guaiac negative
-Labs:
9.0>9.0/28.8<173
Na 139 | K 5.1 | Cl 106 | HCO3 21 | BUN 27 | Cr 1.8
Albumin 3.3 | proBNP: 3281
-Studies:
==========
CT Abdomen/Pelvis w/out contrast - ___
1. Mild bladder wall thickening, which could be secondary to
underdistention and/or chronic outlet obstruction, although
cystitis could have a similar appearance. Recommend correlation
with urinalysis.
2. Moderate hydronephrosis of the right lower quadrant
transplant
kidney, as seen on prior ultrasound.
3. Stable, 3 mm nonobstructing stone within the upper pole of
the
transplant kidney.
4. Small, bilateral pleural effusions.
5. 3 mm pulmonary nodule of the right lower lobe, for which no
dedicated CT follow-up is recommended.
Renal Transplant U/S - ___
1. Redemonstration of moderate transplant hydronephrosis. Small
amount of perinephric free fluid.
2. Patent renal transplant vasculature.
CXR - ___
Streaky left upper lung opacity is seen similar to prior from ___, and may be chronic. There are trace bilateral pleural
effusions. There may be mild pulmonary edema superimposed on
chronic lung changes. Cardiac and mediastinal silhouettes are
stable.
-They were given:
___ 18:44 IV Furosemide 40 mg
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
-ANEMIA
-ESRD S/P KIDNEY TRANSPLANT
-DEPRESSION
-HEPATITIS C
elevated LFTs along with + HCV Ab, HBcAb + in ___ but
subsequently negative; ___: evaluated by Dr. ___, with HCV
RNA PCR >750,000 copies, HepB viral DNA <10, HBeAg/HBeAb
negative. plan to defer treatment. ___: patient with unstable
social situation - intermittently homeless. currently not a
candidate for interferon treatment. will refer to GI if social
situation changes. ___: depression stable, though still
homeless. as LFTs continue to rise, will refer to Dr. ___
recommendations ___: ALT 55, ___ 61, ___ - 52.
___: AST 47, ___ 63, ___ 45
-INSULIN DEPENDENT DIABETES MELLITUS c/b NEPHROPATHY,
RETINOPATHY
AND NEUROPATHY
-SCHIZOAFFECTIVE DISORDER
-HYPERTENSION
-MELANOMA
-HYPERLIPIDEMIA
-CATARACT
-H/O SEIZURE DISORDER
-H/O TUBERCULOSIS
-Pt. received three drug therapy for one year (___)
Social History:
___
Family History:
Mother had ___ and pacemaker.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 98.5PO | BP: 176/92 R Lying | HR: 104 | RR:18 | SpO2: 98 Ra
GENERAL: Pleasant man. Appears older than stated age. Gross
coarse tremors that he attributes to meds side effects.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. faint
systolic murmur heard over the apex.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Non distended, focal tenderness over right flank (above
the graft and not over it). No organomegaly. + BS
EXTREMITIES: +2 pitting edema in left foot (no appreciable edema
over right shins). Right leg: + pitting edema up to knee level
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC/extremities: AOx3. Moving all 4 limbs spontaneously.
CN2-12 intact. ___ strength in upper extremities and ___ in
lower
extremities. Decreased sensation in stocking distribution.
Charcot feet. Onychomycosis.
DISCHARGE PHYSICAL EXAM:
VS 98.2 BP 162 / 83 HR 86 RR18 O2 94 RA
Gen: older man in no acute distress
HEENT: right neck with linear scar, JVP not elevated
CV: regular rate and rhythm, no murmur
Pulm: clear to auscultation bilaterally
Abd: soft, nontender, nondistended; renal graft nontender
Ext: trace pitting edema of lower extremities
Neuro: alert and oriented, moving extremities spontaneously.
Pertinent Results:
ADMISSION LABS:
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___ 01:45PM BLOOD WBC-9.0 RBC-3.25* Hgb-9.0* Hct-28.8*
MCV-89 MCH-27.7 MCHC-31.3* RDW-14.7 RDWSD-47.8* Plt ___
___ 01:45PM BLOOD Glucose-186* UreaN-27* Creat-1.8* Na-139
K-5.1 Cl-106 HCO3-21* AnGap-12
___ 01:45PM BLOOD ALT-15 AST-22 AlkPhos-87 TotBili-0.3
___ 01:45PM BLOOD cTropnT-<0.01 proBNP-3281*
___ 01:45PM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.4 Mg-1.8
Iron-19*
___ 01:45PM BLOOD calTIBC-285 Ferritn-74 TRF-219
___ 01:45PM BLOOD %HbA1c-7.4* eAG-166*
___ 01:45PM BLOOD tacroFK-11.9
URINE STUDIES:
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___ 03:02PM URINE Hours-RANDOM Creat-81 TotProt-130
Prot/Cr-1.6*
___ 02:14AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
IMAGING:
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ECHO ___
CONCLUSION: The left atrial volume index is moderately
increased. There is no evidence for an atrial septal
defect by 2D/color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is mild
(non-obstructive) focal basal septal
hypertrophy. There is normal regional and global left
ventricular systolic function. Quantitative 3D
volumetric left ventricular ejection fraction is 63 %. Left
ventricular cardiac index is normal (>2.5 L/
min/m2). There is no resting left ventricular outflow tract
gradient. No ventricular septal defect is seen.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal
descending aorta diameter. There is no evidence for an aortic
arch coarctation. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is trivial
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial pericardial
effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/
global biventricular systolic function. No valvular pathology or
pathologic flow identified. Mildly
increased right atrial pressure. Mild pulmonary artery systolic
hypertension.
CT ABD/PELV NON CONT ___
IMPRESSION:
1. Moderate hydronephrosis of the right lower quadrant
transplant kidney, as seen on prior ultrasound.
2. Stable, 3 mm nonobstructing stone within the upper pole of
the transplant kidney.
3. Small, bilateral pleural effusions.
4. Trabeculated bladder wall, likely secondary to chronic outlet
obstruction.
5. 3 mm pulmonary nodule of the right lower lobe, for which no
dedicated CT follow-up is recommended.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk
patient, and
an optional CT in 12 months is recommended in a high-risk
patient.
See the ___ ___ Guidelines for the Management
of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
RENAL TRANSPLANT U/S ___:
IMPRESSION:
1. Redemonstration of moderate renal transplant hydronephrosis.
Small amount of perinephric free fluid.
2. Patent renal transplant vasculature. Resistive indices range
from 0.6-0.8.
CXR IMPRESSION: ___
Streaky left upper lung opacity is similar compared to ___ be chronic.
Small bilateral pleural effusions.
Possible mild pulmonary edema superimposed on chronic lung
changes.
PATHOLOGY
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RENAL BIOPSY ___:
PATHOLOGIC DIAGNOSIS:
Renal Allograft needle biopsy ___ years post-transplantation):
Diabetic nephropathy with nodular
glomerulosclerosis, see note.
DISCHARGE LABS:
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================================================================
___ 05:13AM BLOOD WBC-8.8 RBC-3.36* Hgb-9.5* Hct-29.5*
MCV-88 MCH-28.3 MCHC-32.2 RDW-14.6 RDWSD-46.9* Plt ___
___ 05:13AM BLOOD Glucose-110* UreaN-27* Creat-1.8* Na-142
K-4.1 Cl-102 HCO3-26 AnGap-14
___ 06:35AM BLOOD ALT-14 AST-16 LD(LDH)-239 AlkPhos-88
TotBili-0.4
___ 05:13AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.1
___ 05:13AM BLOOD tacroFK-12.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulfameth/Trimethoprim SS 1 TAB PO Q48H
2. Glargine 24 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Vitamin D ___ UNIT PO DAILY
4. Labetalol 600 mg PO BID
5. Ketoconazole 2% 1 Appl TP BID
6. Clozapine 200 mg PO BID
7. ARIPiprazole 5 mg PO QHS
8. Senna 17.2 mg PO QHS
9. Rosuvastatin Calcium 10 mg PO QPM
10. Sodium Bicarbonate 650 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
12. Mycophenolate Mofetil 500 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin B Complex 1 CAP PO DAILY
15. Tacrolimus 1 mg PO Q12H
16. Omeprazole 20 mg PO DAILY
17. amLODIPine 10 mg PO DAILY
18. Oyst-Cal-500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
19. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
every other day Disp #*30 Tablet Refills:*0
2. Torsemide 10 mg PO DAILY
RX *torsemide 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. ARIPiprazole 5 mg PO QHS
5. Ascorbic Acid ___ mg PO DAILY
6. Clozapine 200 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Glargine 24 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Ketoconazole 2% 1 Appl TP BID
10. Labetalol 600 mg PO BID
11. Mycophenolate Mofetil 500 mg PO BID
12. Omeprazole 20 mg PO DAILY
13. Oyst-Cal-500 (calcium carbonate) 500 mg calcium (1,250 mg)
oral DAILY
14. Rosuvastatin Calcium 10 mg PO QPM
15. Senna 17.2 mg PO QHS
16. Sodium Bicarbonate 650 mg PO BID
17. Sulfameth/Trimethoprim SS 1 TAB PO Q48H
18. Tacrolimus 1 mg PO Q12H
19. Tamsulosin 0.4 mg PO QHS
20. Vitamin B Complex 1 CAP PO DAILY
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute kidney injury on chronic kidney disease
Lower extremity edema
Secondary:
ESRD s/p renal transplant
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with dyspnea// chf
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Streaky left upper lung opacity is seen similar to prior from ___,
and may be chronic. There are small bilateral pleural effusions. There may
be mild pulmonary edema superimposed on chronic lung changes. Cardiac and
mediastinal silhouettes are stable.
IMPRESSION:
Streaky left upper lung opacity is similar compared to ___ ___ be
chronic.
Small bilateral pleural effusions.
Possible mild pulmonary edema superimposed on chronic lung changes.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with renal txplt, swelling// transplant eval,
thrombosis
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal ultrasound from ___
FINDINGS:
There is redemonstration of moderate hydronephrosis. There is a small amount
of perinephric free fluid.
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal.
The resistive index of intrarenal arteries ranges from 0.6-0.8. The main
renal artery shows a normal waveform, with prompt systolic upstroke and
continuous antegrade diastolic flow, with peak systolic velocity of 95
centimeters/second. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Redemonstration of moderate renal transplant hydronephrosis. Small amount
of perinephric free fluid.
2. Patent renal transplant vasculature. Resistive indices range from 0.6-0.8.
Radiology Report
EXAMINATION: CT abdomen and pelvis.
INDICATION: ___ with abd pain, recent biopsy, ___ on CKDN// eval for perf,
infection/abscess
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered. Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 557 mGy-cm.
COMPARISON: CT abdomen and pelvis ___. Renal transplant ultrasound
___.
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions. Ground-glass opacities in the
right lower lobe likely reflect atelectasis. A pulmonary nodule of the right
lower lobe measures 3 mm (3:5). A trace pericardial effusion is stable.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas is mildly atrophic. The pancreas has normal
attenuation throughout, without evidence of focal lesions within the
limitations of an unenhanced scan. There is no pancreatic ductal dilatation.
There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The native bilateral kidneys are atrophic. Again seen is a
transplant kidney within the right lower quadrant, demonstrating moderate
hydronephrosis. A nonobstructing stone within the upper pole of the
transplant kidney measures 3 mm, not significant changed from prior. There is
no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. A moderate amount stool is
within the colon. The colon and rectum are otherwise within normal limits.
PELVIS: The bladder wall is mildly thickened and trabeculated, likely
secondary to chronic outlet obstruction. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild-to-moderate
atherosclerotic disease is noted.
BONES: A superior endplate deformity of the L5 vertebral body appears stable,
likely a Schmorl's node. No evidence of acute fracture or worrisome osseous
lesions.
SOFT TISSUES: A focal calcification of the left anterior abdominal wall
(03:46) appears stable. Mild diffuse subcutaneous edema. Otherwise, the
abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Moderate hydronephrosis of the right lower quadrant transplant kidney, as
seen on prior ultrasound.
2. Stable, 3 mm nonobstructing stone within the upper pole of the transplant
kidney.
3. Small, bilateral pleural effusions.
4. Trabeculated bladder wall, likely secondary to chronic outlet obstruction.
5. 3 mm pulmonary nodule of the right lower lobe, for which no dedicated CT
follow-up is recommended.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Acute kidney failure, unspecified
temperature: 98.8
heartrate: 81.0
resprate: 20.0
o2sat: 100.0
sbp: 142.0
dbp: 78.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ year old man with past medical history of
T1DM, retinopathy, neuropathy, Charcot foot, ESRD s/p SCD kidney
transplantation in ___, repeated skin cancers related to
immune
suppression, hx of Hep C (undetectable vital load in ___, HTN,
who came to the ED with weight gain, swelling over face and
legs.
ACTIVE ISSUES
=============
# Weight gain
# Bilateral lower extremities edema
# Pulmonary congestion on CXR
Patient presented with reported weight gain of ___ lbs over 5
days along with new bilateral lower extremity edema. Patient
reassuringly asymptomatic with no dyspnea or chest pain. BNP
elevated to 3200 with negative troponin. No evidence of
cirrhosis on CT A/P. Patient received 40 IV Lasix in the ED with
some improvement in ___ edema. Echocardiogram performed with
normal systolic function, notably with enlarged left atrial and
mildly elevated pulmonary artery systolic pressure to 27. Given
hemodynamic stability, and reassuring volume exam with only mild
edema of lower extremities, patient started on oral diuretic of
torsemide.
# ESRD s/p SCD kidney transplantation in ___:
# ___ on CKD:
Cr. 1.8 on admission, up from baseline of 1.3-1.5. Renal
transplant U/S demonstrated moderate hydronephrosis stable from
prior with patent transplant vasculature. Of note, patient
underwent renal biopsy on ___, which demonstrates diabetic
nephropathy with nodular glomerulosclerosis. UA demonstrated
proteinuria with Pr/Cr ratio of 1.6. Creatinine improved to 1.6
and then on repeat 1.8, which notably in setting of
supratherapeutic tacrolimus.
# Anemia
Hgb 9.0, on repeat 9.5. MCV wnl. Iron studies with low serum
iron, but otherwise unremarkable. Baseline appears to be ___.
Stool guaiac was negative. Last colonoscopy in our system ___.
Due for repeat. Started on PO iron.
# Incidental lung finding:
3 mm pulmonary nodule of the right lower lobe, for which no
dedicated CT follow-up is recommended. RECOMMENDATION(S): For
incidentally detected single solid pulmonary nodule smaller than
6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk
patient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ transferred from ___ with chest pain found to have
NSTEMI.
Patient was in his USOH until 1am on ___, when he developed
the acute onset of ___ burning substernal chest and back pain
that awoke him from sleep. He had no associated SOB, N/V/D or
diarphoresis. He noted the pain somewhat improved by later that
morning, but he continued to have a ___ 'ache' substernally. He
then presented to ___, where he was given ASA 325 and nitro
0.4 x 3 without effect. He then received morphine 5mg at 1830
which caused bradycardia to the ___ with a BP of 79/40. He was
placed in ___ and given IVF with return of vital
signs. OSH labs were notable for trop of 1.0, CKMB of 76.4, INR
1.1, HCT 39.7, and plt 165. He was then transferred for further
management.
In the ___ intial vitals were pain 2, T 98.7, HR 65, BP 116/67,
RR 20, O2 99%3LNC. EKG was notable for qwaves V5-V6,I, and AVL
with TWI in I and AVL. Initial labs were notable for troponin of
1.35. CXR showed mediastinum of ~8cm and signficant subcutaneous
tissue. Patient received plavix 300mg and started on a heparin
gtt before admission to cardiology for futher management.
On the floor, patient reports he is chest pain free. He denies
recent fevers or chills. No shortness of breath or cough. He
denies orthopnea or PND. No recent nausea, vomiting or diarrhea.
No symptoms of claudication. He does have baseline urinary
urgency and some left elbow pain. Review of systems otherwise
unremarkable.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-BPH
-Glaucoma
Social History:
___
Family History:
FAMILY HISTORY:
Father died of MI at age ___. No other family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
VSS
General: Well appearing man in NAD. Pleasant and appropriate
HEENT: Anicteric sclerae, PERLL, OP clear
Neck: JVD not appreciably elevated
CV: Soft S1/S2. No appreciated murmurs, rubs or gallops.
Lungs: CTAB. Nonlabored on NC
Abdomen: Soft, NT/ND
GU: Deferred
Ext: Warm, well perfused. 2+ peripheral pulses throughout.
Neuro: Alert, oriented x3. CNII-XII intact. Moving all
extremities equally. Gait deferred.
Skin: Warm, no rashes or lesions noted
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
___ 04:15AM BLOOD WBC-9.1 RBC-3.95* Hgb-12.1* Hct-36.4*
MCV-92 MCH-30.5 MCHC-33.2 RDW-12.1 Plt ___
___ 04:15AM BLOOD ___ PTT-55.0* ___
___ 04:15AM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-25 AnGap-13
___ 04:15AM BLOOD CK(CPK)-719*
___ 04:15AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.0 Cholest-160
OTHER RELEVANT LABS:
___ 09:05PM BLOOD cTropnT-1.35*
___ 04:15AM BLOOD CK-MB-41* MB Indx-5.7 cTropnT-1.81*
___ 03:15AM BLOOD CK-MB-13* MB Indx-2.8 cTropnT-2.66*
___ 04:15AM BLOOD %HbA1c-5.6 eAG-114
___ 04:15AM BLOOD Triglyc-67 HDL-47 CHOL/HD-3.4 LDLcalc-100
DISCHARGE LABS:
IMAGING:
EKG ___:
Sinus arrhythmia. Borderline first degree A-V delay. Probable
left ventricular hypertrophy. Possible lateral myocardial
infarction of indeterminate age. Non-specific ST-T wave
abnormalities. No previous tracing available for comparison.
CXR ___:
FINDINGS: Frontal and lateral views of the chest were obtained.
There is no focal consolidation, pleural effusion or
pneumothorax. Heart size is top-normal. Mediastinal silhouette
and hilar contours are normal without evidence of mediastinal
widening.
IMPRESSION: Normal mediastinum.
TTE ___:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the
inferior, inferolateral, and lateral walls. The remaining
segments contract normally (LVEF = 50-55 %). The estimated
cardiac index is normal (>=2.5L/min/m2). Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened (?#). There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Physiologic
mitral regurgitation is seen (within normal limits). The
estimated pulmonary arterial systolic pressure is normal. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Regional dysfunction c/w CAD (circumflex
distribution) with overall low-normal global systolic function.
Mildly dilated ascending aorta with mild aortic regurgitation.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Terazosin 10 mg PO HS
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Terazosin 10 mg PO HS
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
4. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
5. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
NSTEMI: 100% occlusion of left circumflex artery, s/p DES
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain. Evaluate for widened mediastinum.
COMPARISON: Portable radiograph ___
FINDINGS: Frontal and lateral views of the chest were obtained. There is no
focal consolidation, pleural effusion or pneumothorax. Heart size is
top-normal. Mediastinal silhouette and hilar contours are normal without
evidence of mediastinal widening.
IMPRESSION: Normal mediastinum.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with MYOCARDIAL INFARCTION NOS, INIT EPISODE OF CARE
temperature: 98.7
heartrate: 65.0
resprate: 20.0
o2sat: 99.0
sbp: 116.0
dbp: 67.0
level of pain: 2
level of acuity: 2.0 | Mr. ___ is a ___ with a PMHx of BPH who was transferred
from ___ with chest pain found to have NSTEMI.
# NSTEMI
Patient with presentation c/w late NSTEMI with positive cardiac
enzymes without ST elevations. He was maintained on heparin gtt.
Mild persistent chest pain, evaluated by cards in ___ and
underwent LCH on ___. He was found to have extensive thrombus
in LCX and underwent thrombectomy, balloon dilatation and
placement of ___. He was maintained on metoprolol,
atorvastatin and lisinopril, plavix and full dose aspirin.
# PUMP: TTE showed depressed EF 50-55%. No clinical signs of
heart failure; pt remained euvolemic.
# RHYTHM: NSR on Telemetry
# BPH: Con't Terazosin and finasteride |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Candesartan / lactose / baclofen
Attending: ___
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CKD on dialysis, CAD, diastolic CHF, and
diabetes presents with respiratory distress. Patient noted to
have significant cough and feeling generally unwell. DNR/DNI
status confirmed. No reports of vomiting, chest pain, abdominal
pain, leg swelling, rash, dysuria.
In the ED, initial vitals were:
Temp 98.4, HR 88, BP 118/92, RR 18, 93% NRB
- Labs notable for:
WBC 16.2 (88% Neutrophils), Hg 10.4, platelets 234
Na 131, K 5.7, Cl 87, bicarb 19, BUM=N 66, Cr 4.5
___: 34___, Trop-T 0.06, lactate 2.4
Flu A PCR positive.
- Imaging was notable for:
1. Consolidation in the right lower and left upper and lower
lobes, concerning for multifocal pneumonia.
2. No evidence of colitis or other acute intra-abdominal
process.
3. Extensive atherosclerotic disease, including severe
calcification of the celiac axis and SMA. Evaluation for
mesenteric ischemia is limited on this noncontrast study.
4. Extensive multilevel degenerative changes of the imaged
spine, not
significantly changed compared to ___.
- Patient was given:
IV Piperacillin-Tazobactam 4.5 g
IV Vancomycin 100 mg
PO/NG OSELTAMivir 75 mg
IV Morphine Sulfate 2 mg
Patient noted to be dyspneic over the last week days also with
nausea/vomiting. Per daughter noted mostly to be phlegm like.
She was also noted to have chills at home. Patient lives at
rehab facility--at that time she had CXR, UA, and blood tests
that her daughter notes were normal. She has a prior history of
aspiration pneumonia.
Per daughter patient denied abdominal pain, chest pain, or
diarrhea.
Has chronic back pain and body aches.
At baseline, patient is typically alert and oriented X 2 per
daughter.
Upon arrival to the floor, patient is able to shake her head
yes/no to questions. She denies pain, chest pain, shortness of
breath, fever, or chills.
Past Medical History:
-HTN
-HLD
-DM
-CKD on dialysis
-Coronary artery disease s/p bypass in ___ years prior
-seizure history---occurs with UTI or infection
-seizure typically rhythmic movements of hands and legs per
daughter
Social History:
___
Family History:
Two children have died, two children with cancer (prostate,
liver). +HTN, +DM type II
Physical Exam:
ADMISSION PHYSICAL EXAM:
==============================
VITAL SIGNS: Temp. 98.2 BP 149 / 64 HR 81 RR 20 ___
GENERAL: comfortable appearing, elderly woman in no acute
distress. Shakes head yes/no to questions
CARDIAC: RRR
LUNGS: bilateral rhonci in all lung fields
ABDOMEN: soft, non-tender to palpation
EXTREMITIES: no edema, warm and well-perfused
NEUROLOGIC: grossly moving all extremities
SKIN: Stage II decub at sacrum. Foot ulcers on ___ toe of both
feet.
DISCHARGE PHYSICAL EXAM:
==============================
VITAL SIGNS: T 98-98.6, BP 149-174/64-71, P 95-106, RR ___,
O2sat 89-100% on ___ NC
GENERAL: pleasant, thin elderly female, no acute distress
HEENT: MMM, EOMI
CARDIAC: RRR, normal S1/S2 no m/r/g.
LUNGS: b/l wheezing in upper posterior lung fields, inspiratory
crackles diffusely
ABDOMEN: soft, non-tender to palpation
EXTREMITIES: no edema, warm and well-perfused
NEUROLOGIC: grossly moving all extremities, A&Ox3, nonfocal
SKIN: Stage II decub at sacrum. Foot ulcers on ___ toe of feet
bilaterally
Pertinent Results:
ADMISSION LABS:
=====================
___ 05:45PM BLOOD WBC-16.2*# RBC-3.61* Hgb-10.4* Hct-34.2
MCV-95 MCH-28.8 MCHC-30.4* RDW-15.5 RDWSD-53.6* Plt ___
___ 05:45PM BLOOD Neuts-88.6* Lymphs-3.8* Monos-6.9
Eos-0.1* Baso-0.1 Im ___ AbsNeut-14.34*# AbsLymp-0.62*
AbsMono-1.11* AbsEos-0.01* AbsBaso-0.02
___ 05:45PM BLOOD ___ PTT-33.2 ___
___ 03:00PM BLOOD Glucose-175* UreaN-66* Creat-4.5*#
Na-131* K-5.7* Cl-87* HCO3-19* AnGap-31*
___ 03:00PM BLOOD ___
___ 03:00PM BLOOD cTropnT-0.06*
___ 03:00PM BLOOD Phos-4.2
___ 03:19PM BLOOD Lactate-2.4*
___ 04:10PM OTHER BODY FLUID FluAPCR-POSITIVE
FluBPCR-NEGATIVE
OTHER RELEVANT LABS:
======================
___ 06:35AM BLOOD WBC-17.4* RBC-3.50* Hgb-10.0* Hct-31.7*
MCV-91 MCH-28.6 MCHC-31.5* RDW-15.3 RDWSD-50.8* Plt ___
___ 06:30AM BLOOD WBC-9.3 RBC-3.37* Hgb-9.7* Hct-32.3*
MCV-96 MCH-28.8 MCHC-30.0* RDW-15.6* RDWSD-54.2* Plt ___
___ 06:04AM BLOOD WBC-8.0 RBC-3.11* Hgb-8.9* Hct-29.2*
MCV-94 MCH-28.6 MCHC-30.5* RDW-15.8* RDWSD-53.3* Plt ___
___ 02:59PM BLOOD WBC-8.3 RBC-3.06* Hgb-8.7* Hct-29.2*
MCV-95 MCH-28.4 MCHC-29.8* RDW-15.7* RDWSD-55.3* Plt ___
___ 06:35AM BLOOD Glucose-110* UreaN-76* Creat-5.4* Na-130*
K-6.2* Cl-88* HCO3-20* AnGap-28*
___ 06:30AM BLOOD Glucose-171* UreaN-14 Creat-1.9* Na-140
K-4.0 Cl-98 HCO3-29 AnGap-17
___ 06:04AM BLOOD Glucose-220* UreaN-42* Creat-3.6* Na-133
K-5.0 Cl-92* HCO3-28 AnGap-18
___ 02:59PM BLOOD Glucose-261* UreaN-12 Creat-1.4*# Na-135
K-4.7 Cl-96 HCO3-31 AnGap-13
___ 07:55AM BLOOD CK-MB-3 cTropnT-0.12*
___ 04:00PM BLOOD CK-MB-3 cTropnT-0.12*
___ 06:35AM BLOOD Calcium-8.5 Phos-5.1* Mg-2.2
___ 06:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
___ 02:59PM BLOOD Calcium-7.7* Phos-2.6* Mg-1.8
MRSA SCREEN (Final ___: No MRSA isolated.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS:
========================
___ 07:00AM BLOOD WBC-10.4* RBC-3.24* Hgb-9.2* Hct-30.8*
MCV-95 MCH-28.4 MCHC-29.9* RDW-15.8* RDWSD-55.0* Plt ___
___ 07:00AM BLOOD Glucose-244* UreaN-22* Creat-2.2* Na-136
K-3.7 Cl-94* HCO3-32 AnGap-14
___ 07:00AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.9
CXR (___): IMPRESSION: Interval progression of the parenchymal
opacity in the left mid lung worrisome for pneumonia.
CT Abdomen and Pelvis without contrast (___):
1. Multifocal pneumonia.
2. No evidence of colitis or other acute intra-abdominal
process.
3. Extensive atherosclerotic disease, including severe
calcification of the celiac axis and SMA.
4. Extensive multilevel degenerative changes of the imaged
spine, not
significantly changed compared to ___.
TTE ___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size is normal with mild global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate to severe
(3+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation. At
least moderate pulmonary hypertnesion.
Medications on Admission:
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Famotidine 20 mg PO DAILY
4. LevETIRAcetam 500 mg PO BID
5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
6. Aspirin 81 mg PO DAILY
7. Citalopram 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. LevETIRAcetam 500 mg PO THREE TIMES PER WEEK POST HD
12. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Medications:
1. Benzonatate 100 mg PO TID Duration: 10 Days
2. Carvedilol 12.5 mg PO BID
Hold for SBP < 110 or HR < 60.
3. GuaiFENesin ___ mL PO Q6H cough Duration: 10 Days
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. Levofloxacin 500 mg PO Q48H Duration: 1 Dose
To be given POST-dialysis on ___ to complete her course.
6. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
Hold for SBP < 110.
7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Citalopram 20 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Famotidine 20 mg PO DAILY
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. LevETIRAcetam 500 mg PO THREE TIMES PER WEEK POST HD
16. LevETIRAcetam 500 mg PO BID
17. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Influenza
Health-care associated pneumonia
New-onset atrial fibrillation
Chronic Kidney Disease Stage 4
Secondary
Chronic heart failure with preserved EF
Coronary artery disease
Hyperlipidemia
Seizure disorder
Glaucoma
GERD
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough, sob // PNA
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Elevation of the right hemidiaphragm is again seen.
FINDINGS:
There is been interval progression of the parenchymal opacity in the left mid
and lower lung since prior. Irregular opacities in the right suprahilar
region are not significantly changed. Cardiac silhouette is unchanged.
Median sternotomy hardware is again noted. No acute osseous abnormalities.
IMPRESSION:
Interval progression of the parenchymal opacity in the left mid lung worrisome
for pneumonia.
Radiology Report
EXAMINATION: CT abdomen pelvis without contrast
INDICATION: ___ with diffuse abdominal pain and low grade fevers. Evaluate
for colitis or other acute intra-abdominal process.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.Oral contrast was not administered. Coronal and sagittal
reformations were performed and reviewed on PACS.
DOSE:
Total DLP (Body) = 531 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: New consolidation in the right lower and left upper and lower
lobes, concerning for pneumonia. Cardiomegaly with extensive 3 vessel
coronary artery calcification. There are post CABG changes. There is
extensive atherosclerotic calcification of the aortic arch and head and neck
vessels. There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. Mild intrahepatic biliary dilatation and dilatation of the CBD is
likely secondary to cholecystectomy.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are unchanged partially calcified cysts in the right kidney.
The bilateral kidneys are atrophic. There is an unchanged left renal cyst.
The kidneys are of normal and symmetric size. There is no evidence of focal
renal lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Diverticulosis of the sigmoid
colon is noted, without evidence of wall thickening and fat stranding. Mild
fecal loading. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. Again seen is extensive calcification of the celiac axis
and SMA. There is a stent in the SMA.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Unchanged grade 2 anterolisthesis of L4 on L5 with bilateral pars defects.
Minimal grade 1 retrolisthesis of L2 on L3. There are extensive multilevel
degenerative changes, evidenced by disc space narrowing, endplate sclerosis,
vacuum disc phenomena and facet hypertrophy. Median sternotomy wires are
partially imaged. The patient is status post left total hip arthroplasty.
SOFT TISSUES: There are multiple calcifications in the posterior subcutaneous
soft tissues overlying the gluteal musculature, likely representing injection
granulomas. There multiple subcutaneous nodules in the anterior pelvis
subcutaneous fat, possibly representing injection granulomas.
IMPRESSION:
1. Multifocal pneumonia.
2. No evidence of colitis or other acute intra-abdominal process.
3. Extensive atherosclerotic disease, including severe calcification of the
celiac axis and SMA.
4. Extensive multilevel degenerative changes of the imaged spine, not
significantly changed compared to ___.
Radiology Report
INDICATION: ___ year old woman with influenza and superimposed bacterial
pneumonia // ? interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Persisting opacities throughout the left mid and lower lung zones. New and
increasing opacities in the right upper lobe as well as at the right lung base
are also noted. No pneumothorax. The appearance of the cardiomediastinal
silhouette is unchanged.
IMPRESSION:
Persisting multifocal pneumonia as described above.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Pneumonia, unspecified organism
temperature: 98.4
heartrate: 88.0
resprate: 18.0
o2sat: 93.0
sbp: 118.0
dbp: 92.0
level of pain: UTA
level of acuity: 2.0 | ___ with history of CKD on dialysis, CAD, seizures, and HFpEF
who presented with respiratory distress and was found to have
multifocal pneumonia and influenza, with likely new onset AF in
the setting of infection.
#Influenza/Pnemonia: Patient was treated with a 5 day course of
Tamiflu (___) and started on coverage for HCAP with an 8
day course of levofloxacin 500 mg q48h (end ___. Patient
required ___ O2 and improvement in her symptoms and oxygen
status was noted with treatment.
#Atrial fibrillation- Patient was noted to have intermittent
episodes of Afib during this hospitalization, with no prior
diagnosis previously. Patient was started on carvedilol 12.5 mg
BID given patient's hypertension. Regarding anticoagulation,
patient's cardiologist was contacted and recommended deferring
anticoagulation given likely provoked AF in the setting of acute
illness and the fact that patient is already of dual
antiplatelet therapy. Patient was discharged with ___ of
hearts monitor at discharge with plans to follow-up with Dr.
___.
# TTE performed ___ showed: Symmetric LVH with normal global
and regional biventricular systolic function. Moderate to severe
mitral regurgitation. Moderate to severe tricuspid
regurgitation. At least moderate pulmonary hypertnesion.
#HTN- Patient was found to be persistently hypertensive so her
dose of imdur was increased to 60 mg daily. Patient was also
started on carvedilol 12.5 mg BID. Discharge BP: 124/64.
# CKD Stage 4- Patient received HD on MWF.
# Diastolic CHF (EF ~60%): Patient with no e/o heart failure
clinically. BNP likely
elevated in setting of CKD. Patient's isosorbide mononitrate was
increased to 60 mg daily. Patient was also started on carvedilol
12.5 mg BID as above.
# CAD/HLD with history of bypass ___ years ago. Patient was
continued on home doses of atorvastatin, plavix, aspirin. Imdur
increased to 60 mg daily. Carvedilol was added as above.
# Seizure history: Patient has a history of seizures during
times of infection per patient's daughter that manifest as
rhythmic jerking of the arms and legs. No evidence of these
seizures during this admission. Patient was continued on keppra
500 mg BID and keppra 500 mg tablet ___ after each HD session.
# Glaucoma- Patient was continued on latanoprost 0.005 % drops
(ophthalmic)
# GERD- Continued famotidine 20 mg q24h
# Depression- Continued celexa 20 mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure, Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ man with a history of atrial
fibrillation, CAD s/p multiple stents and recent 3V CABG ___,
___ w/ LVEF 22% (___), CKD, cirrhosis s/p liver transplant
(___) on tacro, IDDM, and peripheral arterial disease s/p
multiple stents, who presents to the ED after transfer from an
outside hospital for first time seizure at rehab. History is
obtained from prior documentation, as he is unable to provide
any history.
He has been staying at ___ since his recent
hospitalization for CABG in ___. He has generally been
well, although there is mention of a possible fall with head
strike approximately 2 weeks ago. It is not clear that any
further medical workup was pursued at that time. The
circumstances of the fall are otherwise unclear.
Notably, lab work drawn yesterday at rehab showed a calcium of
3.4 and a magnesium was also very low, although the exact value
is not documented. He was also found to have a positive UA with
3+ bacteria and many bacteria on the culture. It is not clear if
any of these were acted upon.
Today, he was witnessed to have a seizure, described as a
tonic-clonic seizure, lasting approximately 3 minutes.
Afterwards, it is documented that he was confused but otherwise
his exam was nonfocal. He has no history of seizure. Glucose at
the time was found to be 66. He was brought to ___
___, where his calcium was found to be 5.1, and again his
magnesium was very low. He was given 2 g of magnesium and
transferred here. He was not given any benzodiazepine or
antiepileptic drugs.
In the ED, initial VS were: 98.0 79 132/78 17 95% RA. Vitals
remained stable at time of transfer.
Exam notable for: alert, oriented to name only
___ nystagmus, pupils sluggish but symmetrically reactive
neuro exam otherwise normal
well healing sternotomy scar
EKG: inverted T waves similar to prior s/p CABG, no new STTW
changes, SR
Labs showed: Ca 6.4 -> 6.5 after two doses of IV calcium albumin
2.7. Mg 1.4 -> ___ s/p IV mag. INR 2.0. Cr 1.1. Lactate normal.
Trop 0.12 x2.
Imaging showed: CXR w/ no PNA.
Consults: neurology recommended hypoCa w/u, no imaging, AEDs, or
LP at this time.
Patient received:
___ 14:32 IV Calcium Gluconate 2 g
___ 15:34 IV Calcium Gluconate 2 g
___ 22:16 IV Calcium Gluconate 2 g
___ 18:20 IV Magnesium Sulfate 4 g
___ 20:23 PO Tacrolimus 1.5 mg
___ 20:33 PO/NG Atorvastatin 80 mg
___ 20:33 PO/NG Warfarin .5 mg
On arrival to the floor, patient reports ***
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Alcoholic cirrhosis s/p orthotopic deceased donor liver
transplant ___
Coronary artery disease, stents to LAD and LCX on ___, DES
to proximal and mid RCA on ___, DES to OM1 on ___ with
diseased RCA that was not amenable to PCI
Atrial fibrillation on rivaroxaban
HFpEF (55%-60%)
Diabetes, insulin-dependent
Hyperlipidemia
CKD (baseline Cr ~1.2-1.3)
Peripheral arterial disease
His vascular history includes the following:
1. ___, angioplasty and stenting of left superficial
femoral artery by Dr. ___.
2. ___, angiogram by Dr. ___.
3. ___nd proximal superficial femoral
endarterectomy with Dacron patch angioplasty by Dr. ___.
4. ___, right groin exploration with removal of Dacron
patch and redo patch angioplasty with ipsilateral greater
saphenous vein under general anesthesia by Dr. ___.
5. ___, left groin cutdown with left common femoral
artery endarterectomy with transition to left external iliac
artery to superficial femoral artery Dacron bypass with
interposition graft. Reimplantation of profunda femoral artery
at the Dacron bypass graft.
6. ___, treatment of right popliteal occlusion with
Zilver 7 x 40 mm stent, treatment of left superficial femoral
artery occlusion with a Zilver 7 x 60, then two Zilver 7 x 80
stents.
Social History:
___
Family History:
Father died ___ years old from MI.
Mother also had heart disease but unsure what kind.
Physical Exam:
Admission Physical Exam
=========================
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical Exam
===========================
GENERAL: Well-developed, well-nourished male laying in bed. NAD.
HEENT: Normocephalic, atraumatic. PERRLA, EOMI. Sclera
anicteric.
No oropharyngeal lesions.
CV: RRR, normal S1/S2, no murmurs, rubs, or gallops. Well-healed
sternotomy scar noted.
RESP: CTAB, no wheezes, rales, or rhonchi.
GI: Soft, nontender, nondistended. NABS. No rebound or guarding.
Well-healed OLT scar noted.
SKIN: No lesions or rashes
NEURO: AAOx3 this AM (waxes and wanes). CNII-XII intact. ___
strength throughout. No focal deficits. Able to follow commands.
No asterixis or nystagmus present. Able to perform days of week
backwards. Normal heal-shin and finger-nose.
PSYCH: Appropriate mood and affect.
Pertinent Results:
Admission Labs
===============
___ 03:09PM BLOOD WBC-6.2 RBC-3.81* Hgb-11.0* Hct-32.8*
MCV-86 MCH-28.9 MCHC-33.5 RDW-15.9* RDWSD-50.3* Plt ___
___ 03:09PM BLOOD ___ PTT-29.9 ___
___ 03:09PM BLOOD Glucose-118* UreaN-26* Creat-1.1 Na-142
K-3.9 Cl-104 HCO3-24 AnGap-14
___ 03:09PM BLOOD ALT-64* AST-63* CK(CPK)-375* AlkPhos-58
TotBili-0.8
___ 03:09PM BLOOD Albumin-2.7* Calcium-6.4* Phos-3.7
Mg-1.4*
___ 03:09PM BLOOD tacroFK-2.8*
___ 03:35PM BLOOD Lactate-1.3
Pertinent Interval Labs
========================
___ 03:09PM BLOOD Albumin-2.7* Calcium-6.4* Phos-3.7
Mg-1.4*
___ 07:40PM BLOOD Calcium-6.5* Phos-3.5 Mg-1.9
___ 09:00AM BLOOD Calcium-7.8* Phos-3.2 Mg-1.5*
___ 07:46AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.7
___ 08:04AM BLOOD Calcium-8.2* Phos-2.5* Mg-1.8
___ 07:34AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.4*
___ 07:40PM BLOOD 25VitD-14*
___ 03:42PM BLOOD PTH-54
___ 01:34AM BLOOD freeCa-0.89*
Discharge Labs
===============
___ 07:34AM BLOOD WBC-6.2 RBC-3.44* Hgb-10.0* Hct-29.3*
MCV-85 MCH-29.1 MCHC-34.1 RDW-15.3 RDWSD-47.3* Plt ___
___ 07:34AM BLOOD Glucose-155* UreaN-24* Creat-1.1 Na-138
K-4.2 Cl-104 HCO3-22 AnGap-12
___ 07:34AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.4*
___ 07:34AM BLOOD tacroFK-3.4*
Imaging Studies
================
CXR ___
Lungs are low volume with no evidence of pneumonia. There are
old healed
right-sided rib fractures. Cardiomediastinal silhouette is
stable. Vascular calcifications again seen. Previously
visualized right IJ line has been removed in the interim. There
is no pleural effusion. No pneumothorax is seen
Microbiology
=============
Blood and urine cultures - no growth to date
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Calcium Carbonate 1000 mg PO BID
4. Creon 12 3 CAP PO QIDWMHS
5. Fenofibrate 145 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Tacrolimus 1.5 mg PO Q12H
13. Amiodarone 200 mg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Lactulose 30 mL PO DAILY
18. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal conjestion
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
20. ___ MD to order daily dose PO DAILY16
21. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
22. Warfarin 0.5 mg PO ONCE atrial fibrillation
23. Ferrous Sulfate 325 mg PO BID
24. Furosemide 20 mg PO ONCE
25. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
26. Meclizine 25 mg PO Q8H:PRN vertigo
27. Milk of Magnesia 30 mL PO QAM:PRN Constipation
28. Potassium Chloride 20 mEq PO DAILY
29. TraZODone 25 mg PO Q6H:PRN Agitation
30. Ondansetron 8 mg PO Q8H:PRN Nausea
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Thiamine 100 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Amiodarone 200 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcium Carbonate 1000 mg PO BID
9. Creon 12 3 CAP PO QIDWMHS
10. Docusate Sodium 100 mg PO BID
11. Fenofibrate 145 mg PO DAILY
12. Ferrous Sulfate 325 mg PO BID
13. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. Lactulose 30 mL PO DAILY
16. Lisinopril 10 mg PO DAILY
17. Magnesium Oxide 400 mg PO DAILY
18. Meclizine 25 mg PO Q8H:PRN vertigo
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Milk of Magnesia 30 mL PO QAM:PRN Constipation
21. Multivitamins W/minerals 1 TAB PO DAILY
22. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
23. Ondansetron 8 mg PO Q8H:PRN Nausea
24. Pantoprazole 40 mg PO Q12H
25. Polyethylene Glycol 17 g PO DAILY:PRN constipation
26. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal conjestion
27. Tacrolimus 1.5 mg PO Q12H
28. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
29. TraZODone 25 mg PO Q6H:PRN Agitation
30. ___ MD to order daily dose PO DAILY16
31. HELD- Furosemide 20 mg PO ONCE This medication was held. Do
not restart Furosemide until seen by pcp or rehab provider
32. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until seen by pcp or
rehab provider
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
===================
Seizure
Hypocalcemia
Vitamin D deficiency
Secondary Diagnoses
====================
S/p Liver Transplant
Transaminitis
Delirium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with seizure// ?cpd
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with no evidence of pneumonia. There are old healed
right-sided rib fractures. Cardiomediastinal silhouette is stable. Vascular
calcifications again seen. Previously visualized right IJ line has been
removed in the interim. There is no pleural effusion. No pneumothorax is
seen
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 98.0
heartrate: 79.0
resprate: 17.0
o2sat: 95.0
sbp: 132.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | Transitional Issues
====================
[ ] Furosemide and potassium supplementation - held in the
setting of ___, hypocalcemia. Can be restarted on an outpatient
basis
[ ] Seizure precautions - given history of seizure patient
should not drive (per state laws), operate heavy machinery, bath
alone, swim, or climb ladders for 6 months or until cleared by
his primary care physician.
[ ] Transaminitis - attributed to amiodarone, though should be
followed up in the future to ensure stabilization
[ ] Alcohol use - evidence of alcohol use even since his liver
transplant. Alcohol use counseling should be considered in the
outpatient setting.
[ ] Electrolyte abnormalities - calcium, magnesium, and vitamin
D should be check periodically to ensure they are within
adequate levels and repleted prn.
[ ] Please check CMP on ___ and replete as indicated
[ ] Is on warfarin for atrial fibrillation. Was changed from
rivaroxaban on his last hospitalization ___ discharge) to
warfarin. Unclear based on notes the reasoning for the
transition. Will continue warfarin but should be evaluated by
PCP or cardiology regarding restarting rivaroxaban.
[ ] On discharge from rehab, please connect patient to ___
___ clinic. Per ___ clinic, cannot establish care with
their services until after discharge from rehab.
[ ] New medications: thiamine 100mg daily, folic acid 1mg daily,
vitamin D 2000IU daily
___ year old male with CAD s/p multiple stents and recent 3v CABG
___, EtOH cirrhosis s/p OLT in ___ on tacrolimus, atrial
fibrillation on warfarin, HFrEF, CKD, IDDM, and PAD presented
from rehab center with new onset tonic-clonic seizure x1 and
severe hypocalcemia secondary to vitamin D deficiency.
# Seizure
Patient presented from rehab center after sustaining a
tonic-clonic seizure. A work up, including head CT, was
negative. The patient was noted to be severely hypocalcemic,
which is thought to have precipitated his seizures. Neurology
was consulted, who felt that the hypocalcemia was sufficient to
explain the seizures and recommended against EEG and
anti-epileptic medications. Mr. ___ did not suffer any further
seizures after the initial episode.
# Severe hypocalcemia
Presented to OSH with calcium reportedly 5.1. A thorough work up
revealed vitamin D deficiency as well as hypomagnesemia, which
were felt to be the causes of his hypocalcemia. Notably, PTH was
within normal range. Calcium, vitamin D, and magnesium were all
repleted to appropriate levels, and the patient was started on
PO repletion for discharge.
# AMS
The patient suffered from altered mental status throughout his
hospital course, remarkable for waxing and waning features and
altered sleep-wake cycle most indicative of hospital-acquired
delirium. Other causes of AMS were also entertained, most
notably ___'s encephalopathy and hepatic encephalopathy in
the setting of his extensive alcohol abuse history. Ultimately,
it was felt that his presentation was not consistent with
___'s encephalopathy (no nystagmus or evidence of
cerebellar dysfunction) or hepatic encephalopathy (no
asterixis). However, given relatively low impact of vitamin
supplementation and risk of Wernicke's, started patient on
thiamine supplementation per neurology recommendation.
# Alcohol use
Patient had varying reports of the last time he had alcohol, but
collateral acquired from his brother indicated that the patient
had been drinking significant amounts of alcohol since 6 months
after his liver transplant in ___. Given his history of alcohol
use, he was started on MVI, thiamine, and folate.
# ___ on CKD
Patient's baseline Cr appeared to be around 1.0-1.1, but his Cr
was lower on admission. It uptrended on ___ to 1.4, which was
thoguht to be secondary to hypovolemia given patient his was
significantly net
negative based on I/Os. His Cr returned to his presentation
levels with increased fluid intake and kidney function remained
stable for the remainder of his hospital stay. Of note, his home
Lasix was held in the setting of his ___ and should be resumed
on an outpatient basis.
# Transaminitis
# OLT ___
Mildly elevated AST/ALT to the ___ on admission. Patient was
started on amiodarone on previous hospitalization in ___ for
atrial fibrillation, which was the suspected etiology of his
transaminitis. On exam, the patient had a nontender RUQ and no
evidence of
cholestasis on labs. His tacrolimus levels were monitored, and
no dose adjustments were necessary to keep within goal ___ per
hepatology).
Chronic/Stable Medical Issues
==============================
# Atrial fibrillation
- Continued amiodarone
- Continued warfarin
# CAD s/p stenting, 3v CABG
- Continued ASA 81mg
- Continued atorvastatin 80mg daily
- Continued imdur 30mg daily
# HFrEF
EF 22% ___ in setting of hospitalization for CABG
- Held Lasix 20mg daily given hypocalcemia, ___
- Continued lisinopril 10mg
- Continued metoprolol succinate 25mg daily
# IDDM
- Continued home regimen of lantus and Humalog SSI
# PAD s/p stenting
- Continued ASA, statin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with the past medical
history notable for PE at 7wks gestation (___), IVC clot 2wks
post-partum s/p catheter-directed thrombolysis and IVC filter
s/p
removal, and submassive PE in ___ who presented to the
emergency department for evaluation of pleurtic chest pain. She
was seen at ___ where she was found to have bilateral
PEs
with evidence of right heart strain. She was started on TPA and
received a total of 5 mg during transfer and this was DC'd upon
arrival to ___.
At ___ her initial vitals were: 98.7, 85, 110/87, 18, 98% RA.
She was placed on a heparin drip with a initial bolus of 5200
units. Head CT was negative.
BNP was negative, trop was 0.05. Remainder of her labs were
unremarkable. Head CT was negative.
MASCOT recommended the following: Ok for admission to floor
(medicine). Continue heparin. Obtain echo and LENIs. Check APLS
antibodies (anticardiolipin Ab, beta2 glycoprotein). Check BNP.
Vascular medicine to follow as inpatient.
Transfer Vitals: 97.9, 88, 119/94, 22, 98% RA.
On arrival to the floor the patient confirms the above history.
She continues to report pleuritic chest pain, worse with deep
inspiration and located on the left without radiation. She
also
reports sub-sternal chest pain that she reports is sharp in
nature and without radiation. Nothing makes that better or
worse.
She specifically denies dyspnea or dyspnea exertion. She also
reports that she developed presyncope while walking earlier in
the morning and she fell down and struck her knees, but denied
head strike of full loss of consciousness. She reports that she
has not missed any doses of her rivaroxaban. She takes it at
___ every night with a snack like crackers.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
-Possible AT3 deficiency => not likely per
-History of pulmonary emboli now on lifelong anticoagulation.
-History of Preeclampsia
-History of IUGR
-Migraine headaches w/o aura
Social History:
___
Family History:
No family history of bleeding/clotting disorders. Grandmother
with possible DM.
Physical Exam:
VITALS: ___ 1545 Dyspnea: 0 RASS: 0 Pain Score: ___
___ 1614 Temp: 98.3 PO BP: 130/81 HR: 89 RR: 18 O2 sat: 98%
O2 delivery: RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, ___ SEM, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 12:00PM BLOOD WBC: 7.3 RBC: 4.38 Hgb: 13.3 Hct: 38.0
MCV: 87 MCH: 30.4 MCHC: 35.0 RDW: 13.0 RDWSD: 40.___
___ 12:00PM BLOOD Neuts: 66.3 Lymphs: ___ Monos: 7.4 Eos:
0.7* Baso: 0.5 Im ___: 0.4 AbsNeut: 4.87 AbsLymp: 1.81 AbsMono:
0.54 AbsEos: 0.05 AbsBaso: 0.04
___ 12:00PM BLOOD ___: 13.8* PTT: 24.0* ___: 1.3*
___ 12:00PM BLOOD Glucose: 86 UreaN: 14 Creat: 0.8 Na: 138
K: 4.3 Cl: 107 HCO3: 21* AnGap: 10
___ 12:00PM BLOOD cTropnT: 0.05*
___ 12:00PM BLOOD proBNP: 40
I personally reviewed the [X-ray, ECG] and my interpretation is:
EKG: Sinus at 86bpm. Normal Axis. Normal interval. S1Q3T3 (new).
CONCLUSION:
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal
cavity size. There is normal regional and global left
ventricular systolic function. Quantitative 3D
volumetric left ventricular ejection fraction is 54 % (normal
54-73%). Left ventricular cardiac index
is low normal (2.0-2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal
descending aorta diameter. There is no evidence for an aortic
arch coarctation. The aortic valve leaflets
(3) appear structurally normal. There is no aortic valve
stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal with no mitral
valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally
normal. There is mild to moderate [___] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes and
regional/global biventricular systolic
function. Mild-moderate tricuspid regurgitation. Mild pulmonary
artery systolic hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 20 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC Q12H
RX *enoxaparin 100 mg/mL 1 Injection SC every twelve (12) hours
Disp #*60 Syringe Refills:*1
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with s/p fall, on blood thiner// eval for bleed
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Prior exam is dated ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles and sulci are normal in overall size and configuration.
The imaged paranasal sinuses are clear. Mastoid air cells and middle ear
cavities are well aerated. The bony calvarium is intact.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with chronic VTE presents with recurrent PE and
SOB// bilat ___ to eval for new DVT, clot burden
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Ultrasound from ___.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, PE, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale
temperature: 98.7
heartrate: 85.0
resprate: 18.0
o2sat: 98.0
sbp: 110.0
dbp: 87.0
level of pain: 7
level of acuity: 2.0 | ___ woman with h/o PE at 7 wks gestation (___), IVC
clot 2 wks post-partum s/p catheter-directed thrombolysis and
IVC filter s/p removal, and submassive PE in ___ who
presented to the emergency department for evaluation of pleurtic
chest pain, found to have recurrent bilateral pulmonary embolism
with right heart strain despite rivaroxaban.
# Acute submassive PE:
# Chronic VTE:
The patient has a history of recurrent VTE and presents with a
recurrent PE despite AC with rivaroxaban. She denies missing any
doses. She follows with hematology who in their last note wrote:
"Pt has a history of peripartum PE/IVC thrombus without
identified contributing hypercoaguable syndrome (negative APL
abs, AT antigen repeatedly normal). Her IVC filter was removed
___. She was treated with 6 mo therapeutic AC (warfarin ->
Xarelto) then transitioned to ppx ASA 81mg daily on which she
developed a LLL segmental PE (neg trop, BNP) and normal TTE.
During that hospitalization, she underwent a repeat CTA chest 5
days after the diagnostic study which revealed no change in her
exam. She was started on rivaroxaban 20 mg twice daily" She was
transitioned to once daily rivaroxaban. At that time (___)
hematology recommended lifelong anticoagulation. They noted "She
does not have Antithrombin deficiency nor any identified
hypercoagulability syndrome, though it is clear that she remains
at high risk of recurrent thrombosis. Her APLS testing is
negative, so she is safe to be anticoagulated with rivaroxaban."
She missed her most resent hematology follow-up appointment in
___ of this year.
- TTE reviewed, re-assuring
- LENIs negative
- Appreciate Hematology and MASCOT consult recommendations
- Placed on Lovenox ___ q12. ___ cont on DC and have patient
follow up with Dr. ___
- ___ repeat anticardiolipin and B2 glycoprotein testing -
PENDING on DC
- Hold home Rivaroxiban.
- Pain control with acetaminophen 1000mg PO Q6H PRN.
- Avoid NSAIDS for now if possible
# Migraine Headaches:
-Monitor |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd Pain, Confusion, Diarrhea, Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH ESRD due to lithium toxicity s/p LRRT ___ years ago on
azathioprine, prednisone, and tacrolimus, baseline creatinine
~0.9, IBS with chronic diarrhea, OSA on CPAP and 2L O2 at night,
anemia, HTN, severe bipolar disorder, presenting with nausea (no
vomiting), RLQ/vague abdominal pain, and diarrhea for the past
week, with one day of confusion/delirium.
Family reports confusion since yesterday. History per son
primarily though patient adds in additional points. Reports
having nausea for the last week on and off though progressive
and
more frequent last ___ days, with periumbilical/ RLQ pain.
Decreased PO intake of food and water. Denies fever, chills,
chest pain, cough, sob. Son reports she has been forgetful in
last 2 days that is not her baseline. Forgot her meds this
morning, intermittently didn't know where she was, reports this
is very abnormal for her. Denies dysuria though has had UTIs in
the past as well as CDiff. Has baseline diarrhea, denies
worsening symptoms recently. Denies changes in medications.
Denies fall or trauma.
In the ED, initial VS were: 98.6 132/78 80 16 98/RA
ECG: poor quality, sinus, some possible STD in anterior leads
which were present in prior EKG.
Labs showed:
- Nl CBC
- Cr 1.3 Bicarb 17 AG 17 BUN 47 Mg 1.4 phos 2.6 Ca ___ lytes
otherwise WNL
- Trop <0.01
- Lactate 1.2
- INR 1.2
- UA w/ 26 rbc, tr pro
- PTH 148
Imaging showed:
- CTU: Acute uncomplicated diverticulitis of the descending
colon.
- Transplant US: Normal renal transplant ultrasound.
- CXR: Low lung volumes. No evidence of acute cardiopulmonary
process.
Consults: Renal: admit to medicine, transplant team will follow
on the weekend
Patient received:
___ 21:10 IVF NS ___ Started
___ 21:10 IV Magnesium Sulfate ___ Started
___ 22:08 IVF NS 1000 mL ___ Stopped (___)
___ 22:08 IV Magnesium Sulfate 2 gm ___
Stopped (___)
___ 22:09 IVF NS ___ Started
___ 23:34 IVF NS 1000 mL ___ Stopped (1h
___
___ 23:34 IVF NS ( 1000 mL ordered) ___
Started
___ 00:03 IV Ciprofloxacin (400 mg ordered)
___ Started
On arrival to the floor, patient reports ongoing nausea with
mild
abdominal pain. Denies confusion, alert and oriented during our
discussion.
Past Medical History:
- ESRD due to lithium toxicity s/p LRRT ___ on azathioprine,
prednisone, and tacrolimus, baseline creatinine ~0.9, formerly
undergoing plasma exchange for renal sensitization
- IBS with chronic diarrhea
- OSA on CPAP
- anemia
- femur fracture
- HTN
- Questionable history of temporal arteritis versus polymyalgia
rheumatica
- Severe bipolar disorder
- Hyperparathyroidism with hypercalcemia related to lithium
- Vertigo
- Gastroesophageal reflux disease
- Cholecystectomy in ___
- Right knee replacement in ___
- Left benign breast tumor resection ___
- Status post appendectomy
- History of difficult intubation
- ___ ex lap, LOA for ___
Social History:
___
Family History:
Breast cancer in aunt, heart disease; denies hx colon cancer,
diverticulosis.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 0138 Temp: 98.3 PO BP: 136/86 L Lying HR: 74 RR: 20
O2 sat: 98% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, mild tenderness to deep palpation worse
periumbilical and RLQ, no rebound/guarding
EXTREMITIES: no cyanosis, clubbing; trace edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN ___ intact, strength ___ and sensation intact
throughout
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 1000)
Temp: 98.0 (Tm 98.3), BP: 125/82 (108-125/70-82), HR: 63
(63-69), RR: 18, O2 sat: 97% (95-97), O2 delivery: Cpap
GENERAL: Resting in chair in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Very poor dentition.
NECK: Supple with no LAD or JVD.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA
bilaterally. No crackles, wheezes or rhonchi.
ABDOMEN: NTND. +BS.
EXTREMITIES: No c/c/e. Distal pulses palpable and symmetric.
SKIN: Warm, dry, no rashes or obvious lesions.
Pertinent Results:
ADMISSION LABS:
___ 06:00PM BLOOD WBC-7.2 RBC-3.96 Hgb-12.2 Hct-34.9 MCV-88
MCH-30.8 MCHC-35.0 RDW-12.6 RDWSD-40.1 Plt ___
___ 06:00PM BLOOD Neuts-60.0 ___ Monos-9.1 Eos-3.5
Baso-0.7 Im ___ AbsNeut-4.30 AbsLymp-1.86 AbsMono-0.65
AbsEos-0.25 AbsBaso-0.05
___ 06:00PM BLOOD ___ PTT-28.2 ___
___ 06:00PM BLOOD Glucose-82 UreaN-47* Creat-1.3* Na-138
K-4.6 Cl-104 HCO3-17* AnGap-17
___ 06:00PM BLOOD Albumin-3.6 Calcium-10.9* Phos-2.6*
Mg-1.4*
___ 10:09PM BLOOD PTH-148*
IMAGING:
CXR ___:
FINDINGS: Low lung volumes cause bronchovascular crowding and
bibasilar atelectasis. There is no focal consolidation or
pleural effusion, pulmonary edema, or pneumothorax. IMPRESSION:
Low lung volumes. No evidence of acute cardiopulmonary process.
RENAL TRANSPLANT US ___:
FINDINGS: The right iliac fossa transplant renal morphology is
normal. Specifically, the cortex is of normal thickness and
echogenicity, pyramids are normal, there is no urothelial
thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection. The
resistive index of intrarenal arteries ranges from 0.62 to 0.68,
within the normal range. The main renal artery shows a normal
waveform, with prompt systolic upstroke and continuous antegrade
diastolic flow, with peak systolic velocity of 108 cm/s.
Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform. IMPRESSION:
Normal renal transplant ultrasound.
CTU ___:
IMPRESSION: Optimal evaluation of organ pathology and
vasculature is limited without the benefit of intravenous
contrast. Within this limitation, acute uncomplicated
diverticulitis involving a short segment of the descending
colon, located in the left lower quadrant. No surrounding
drainable fluid collection.
MICROBIOLOGY:
___ 7:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood cultures negative
C diff negative
DISCHARGE LABS:
___ 09:10AM BLOOD Glucose-79 UreaN-18 Creat-1.0 Na-140
K-4.0 Cl-105 HCO3-23 AnGap-12
___ 09:10AM BLOOD tacroFK-4.8*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Divalproex (DELayed Release) 250 mg PO TID
3. LamoTRIgine 200 mg PO QHS
4. LamoTRIgine 150 mg PO QAM
5. Cinacalcet 30 mg PO DAILY
6. ARIPiprazole 5 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Alendronate Sodium 35 mg PO QSUN
9. AzaTHIOprine 75 mg PO DAILY
10. Tacrolimus 4 mg PO Q12H
11. Vitamin D 1000 UNIT PO DAILY
12. Venlafaxine XR 300 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*21 Tablet Refills:*0
2. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 2 mg by mouth qid prn Disp #*30 Capsule
Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth q8 Disp
#*31 Tablet Refills:*0
4. Tacrolimus 2 mg PO Q12H
5. ARIPiprazole 5 mg PO DAILY
6. AzaTHIOprine 75 mg PO DAILY
7. Cinacalcet 30 mg PO DAILY
8. Divalproex (DELayed Release) 250 mg PO QAM
9. Divalproex (DELayed Release) 500 mg PO QPM
10. LamoTRIgine 25 mg PO QAM
11. LamoTRIgine 50 mg PO QPM
12. PredniSONE 5 mg PO DAILY
13. Venlafaxine XR 75 mg PO QPM
14. Venlafaxine XR 300 mg PO QAM
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with nausea, evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiographs dating back to ___, most recently
___
FINDINGS:
Low lung volumes cause bronchovascular crowding and bibasilar atelectasis.
There is no focal consolidation or pleural effusion, pulmonary edema, or
pneumothorax.
IMPRESSION:
Low lung volumes. No evidence of acute cardiopulmonary process.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with pain over transplanted kidney, evaluate for
hydronephrosis or change in flow.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Prior renal transplant ultrasound dated ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.62 to 0.68, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 108 cm/s. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ with abd pain, nausea, confusion evaluate for stones,
diverticulitis, or colitis.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP = 530.35 mGy-cm.
COMPARISON: Prior CT of the abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is not visualized.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Bilateral native kidneys are severely atrophic.. There is no
evidence of focal renal lesions within the limitations of an unenhanced scan.
There is no hydronephrosis. There is no nephrolithiasis. There is no
perinephric abnormality. The right iliac fossa transplant kidney is without
evidence of hydronephrosis or focal lesions within limitations of an
unenhanced scan. No stones are seen within this transplant kidney.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. There is wall thickening and
fat stranding around approximately 7 cm segment of the descending colon
consistent with diverticulitis. There is no associated fluid collection. No
free air to suggest perforation. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus contains a calcified fibroids.. No adnexal
abnormalities are seen.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Hardware in the left femoral neck and shaft is noted.
SOFT TISSUES: Fat containing umbilical hernia is noted. Low right lower
quadrant ventral abdominal hernia contains a loop of small bowel without
evidence of obstruction.
IMPRESSION:
Optimal evaluation of organ pathology and vasculature is limited without the
benefit of intravenous contrast.
Within this limitation, acute uncomplicated diverticulitis involving a short
segment of the descending colon, located in the left lower quadrant. No
surrounding drainable fluid collection.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:08 pm, 5 minutes after
discovery of the findings.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain, Confusion, Diarrhea, Nausea
Diagnosed with Unspecified abdominal pain
temperature: 98.6
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 132.0
dbp: 78.0
level of pain: 8
level of acuity: 2.0 | ___ is a ___ yo woman with a history of ESRD due to
lithium toxicity s/p LRRT ___ years ago on azathioprine,
prednisone, and tacrolimus, baseline creatinine ~0.9, IBS with
chronic diarrhea, OSA on CPAP, anemia, HTN, severe bipolar
disorder, presenting with nausea (no vomiting), RLQ/vague
abdominal pain, and diarrhea for the past week, with one day of
confusion/delirium, found to have acute uncomplicated
diverticulosis on CTU, which was successfully managed medically.
# Acute uncomplicated diverticulitis
# Nausea / abdominal pain
# Toxic Metabolic Encephalopathy
Patient presented with nausea, abdominal pain, and 1 day of
confusion. CTU in the ED showed acute uncomplicated
diverticulitis, which would explain symptoms. Renal was
consulted regarding her immunosuppressive medications and
recommended continuation of her regimen as she was relatively
stable and not septic. She was started on IV cipro and PO
flagyl, and was advanced to PO cipro on ___. She was initially
NPO, but by ___ she was tolerating some clears, and her diet
was advanced thereafter. By the day of discharge she was feeling
like herself and was able to walk with her walker. By ___ she
is tolerating diet well.
Per ___ evaluation, she will need rehab, anticipate this will be
less than 30 day stay.
# ___ - Resolved.
# ESRD s/p LRRT in ___
Patient w/ ___ to 1.3 from baseline 0.9. Likely pre-renal in the
setting of dehydration/ diverticulosis as above. S/p 2L NS in ED
and MIVF overnight ___ ___ resolved. Urine Cx negative.
Tacro level 8.5 on ___, dose was decreased to 2mg bid (from
home dose of 4mg BID), level was 10.2 on ___, thus dose was
dropped to 1mg. Recheck of level on ___ was 6.7. Tacro level
likely elevated in the setting of diarrhea. Continued other home
meds: prednisone 5mg daily, and azathioprine 75mg daily. Recheck
on ___ tacro level was 4.7, and she is being discharged, so
final discharge dose will be 2mg BID.
*IMPORTANT* She will need tacro level checked on ___
and fax the labwork to ___.
# Tertiary hyperparathyroidism
# Hypercalcemia
Known history, followed by endocrine. She is on alendronate
weekly (was not dosed while inpt). Continued cinacalcet. Held
cholecalciferol.
# Diarrhea
# IBS
Per patient, daughter, and medical records review, diarrhea
appears to be chronic ISO IBS.
C. diff was checked and was negative. (has history of infection
in ___ and was checked again in ___, was negative). Imodium
was given for sx relief.
# Severe bipolar disorder
Continued divalproex, lamotrigine, aripiprazole, venlafaxine. Of
note, her med doses were incorrectly recoded on her
pre-admission med list. The doses were adjusted and corrected on
___ by our pharmacy team.
# HTN
She was briefly on metoprolol after she was stabilized from an
infectious standpoint, however it was discovered that her home
medication list was incorrect, thus this was discontinued.
# OSA
Uses CPAP and 2L O2 at night. These were continued inpt.
__________________________________ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / latex / walnuts
Attending: ___
Chief Complaint:
pelvic subcutaneous fluid collection
Major Surgical or Invasive Procedure:
___ drainage of pelvic fluid collection
Physical Exam:
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, minimally tender, mildly erythematous around the
drain site improved from admission, no induration or fluctuance
noted, no rebound/guarding, RLQ JP drain intact with
serosanguinous fluid
Ext: no TTP
Pertinent Results:
___ 12:24PM BLOOD Hct-36.2#
___ 05:32AM BLOOD WBC-5.7 RBC-3.22* Hgb-9.6* Hct-28.6*
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.5 RDWSD-44.0 Plt ___
___ 03:40AM BLOOD WBC-7.1 RBC-4.04 Hgb-11.7 Hct-35.4 MCV-88
MCH-29.0 MCHC-33.1 RDW-13.5 RDWSD-43.5 Plt ___
___ 04:00AM BLOOD WBC-7.7 RBC-3.84* Hgb-11.0* Hct-33.7*
MCV-88 MCH-28.6 MCHC-32.6 RDW-13.8 RDWSD-44.0 Plt ___
___ 05:13AM BLOOD WBC-7.8 RBC-4.27 Hgb-12.3 Hct-37.5 MCV-88
MCH-28.8 MCHC-32.8 RDW-14.0 RDWSD-45.2 Plt ___
___ 07:33AM BLOOD WBC-9.6 RBC-3.92 Hgb-11.4 Hct-34.6 MCV-88
MCH-29.1 MCHC-32.9 RDW-14.4 RDWSD-46.1 Plt ___
___ 10:00PM BLOOD WBC-12.5* RBC-4.14 Hgb-11.9 Hct-36.8
MCV-89 MCH-28.7 MCHC-32.3 RDW-14.3 RDWSD-46.1 Plt ___
___ 05:32AM BLOOD Neuts-49 Bands-0 ___ Monos-13 Eos-2
Baso-0 ___ Myelos-0 AbsNeut-2.79 AbsLymp-2.05
AbsMono-0.74 AbsEos-0.11 AbsBaso-0.00*
___ 03:40AM BLOOD Neuts-58 Bands-0 ___ Monos-8 Eos-4
Baso-1 Atyps-3* ___ Myelos-0 AbsNeut-4.12 AbsLymp-2.06
AbsMono-0.57 AbsEos-0.28 AbsBaso-0.07
___ 04:00AM BLOOD Neuts-53.4 ___ Monos-9.8 Eos-4.9
Baso-0.4 Im ___ AbsNeut-4.11 AbsLymp-2.39 AbsMono-0.75
AbsEos-0.38 AbsBaso-0.03
___ 05:13AM BLOOD Neuts-52.2 ___ Monos-9.1 Eos-4.9
Baso-0.4 Im ___ AbsNeut-4.07 AbsLymp-2.57 AbsMono-0.71
AbsEos-0.38 AbsBaso-0.03
___ 07:33AM BLOOD Neuts-46.2 ___ Monos-9.6 Eos-5.9
Baso-0.4 Im ___ AbsNeut-4.41 AbsLymp-3.57 AbsMono-0.92*
AbsEos-0.56* AbsBaso-0.04
___ 10:00PM BLOOD Neuts-53.8 ___ Monos-8.9 Eos-5.0
Baso-0.6 Im ___ AbsNeut-6.71* AbsLymp-3.87* AbsMono-1.11*
AbsEos-0.63* AbsBaso-0.08
___ 07:33AM BLOOD ___ PTT-31.7 ___
___ 10:00PM BLOOD Glucose-179* UreaN-13 Creat-0.7 Na-138
K-4.0 Cl-103 HCO3-22 AnGap-17
___ 12:24PM BLOOD CK(CPK)-50
___ 04:00AM BLOOD ALT-38 AST-20
___ 12:24PM BLOOD CRP-3.6
___ 10:21PM BLOOD Lactate-1.8
Imaging:
___ CT A/P
IMPRESSION:
1. A lower anterior abdominal wall peripherally enhancing fluid
collection
containing locules of air is decreased in size from prior,
currently measuring
up to 9.6 cm, compared with 14.2 cm previously, however is again
concerning
for infected seroma/abscess. This would be amenable to
percutaneous drainage
if desired.
2. A 2.7 cm left adrenal lesion is not significantly changed
from prior,
however is again incompletely characterized. Recommend
correlation with prior
imaging if available, or outpatient MRI/CT adrenal for further
characterization if no prior imaging is available.
3. Hepatic steatosis.
___ CXR PICC
IMPRESSION:
Right-sided PICC line at the appropriate position.
Micro:
___ Abscess Culture
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ENTEROCOCCUS SP.. SPARSE GROWTH.
Daptomycin Susceptibility testing requested by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Medications on Admission:
albuterol, symbicort, fluvoxamine 50mg, glipizide ER 5mg,
hydroxyzine pamoate 50mg, lamotrigine 100mg, lithium carbonate
ER 600mg, metformin 500mg BID, omeprazole 20mg, polyethylene
glycol, prazosin 2mg, simvastatin 20mg, zolpidem 10mg, docusate
sodium, loratidine 10mg, florastor 250mg
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*0
2. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every 4
hours Disp #*60 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*40 Tablet Refills:*0
4. Levofloxacin 750 mg PO Q24H
RX *levofloxacin 750 mg 1 tablet(s) by mouth every 24 hours Disp
#*15 Tablet Refills:*0
5. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*45 Tablet Refills:*0
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
8. Daptomycin 400 mg IV Q24H
RX *daptomycin 500 mg 400 mg IV every 24 hours Disp #*15 Vial
Refills:*0
9. Fluvoxamine Maleate 75 mg PO DAILY
10. GlipiZIDE XL 5 mg PO DAILY
11. HydrOXYzine 25 mg PO BID
12. LamoTRIgine 100 mg PO QHS
13. Lithium Carbonate SR (Lithobid) 600 mg PO QHS
Lithobid SR
14. Loratadine 10 mg PO DAILY
15. MetFORMIN (Glucophage) 500 mg PO BID
16. Omeprazole 20 mg PO BID
17. Prazosin 2 mg PO QHS
18. Simvastatin 20 mg PO QPM
19. Zolpidem Tartrate 10 mg PO QHS
20.Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
DAPTOMYCIN: WEEKLY: CBC with differential, BUN, Cr, CPK
QUINOLONES: 7 DAYS POST DISCHARGE: AST, ALT, TB, ALK PHOS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cellulitis and pelvic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with hx recurrent abscesses p/w
worsening pain, swelling x1dNO_PO contrast// anterior abdominal wall abscess?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 5.2 s, 57.0 cm; CTDIvol = 16.8 mGy (Body) DLP = 959.0
mGy-cm.
Total DLP (Body) = 973 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous hypoattenuation throughout,
consistent with hepatic steatosis. There is no evidence of focal lesions.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. A 2.7 x 2.3 cm
left adrenal lesion is not significantly changed, however is again
incompletely characterized.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Subcentimeter cortical hypodensities bilaterally are too small to
characterize, however likely represent cysts. There is no hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
PELVIS: The dome of the bladder wall again abuts an anterior pelvic wall
collection, with little to no fat plane between the bladder in the collection.
Inflammatory flat stranding again extends deep to the collection, bordering
the anterior peritoneum. The distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Multiple old right-sided healed rib fractures are noted. There are
mild degenerative changes in the lumbar spine. There is no evidence of
worrisome osseous lesions or acute fracture.
SOFT TISSUES: A lower anterior pelvic wall peripherally enhancing fluid
collection containing locules of air is decreased in size from prior,
currently measuring 9.6 x 3.8 x 7.0 cm in greatest dimension, compared with
14.2 x 4.7 x 10.4 cm previously (2:85, 601:24). The attenuation is again of
simple fluid. There is surrounding fat stranding in the anterior abdominal
wall, decreased from prior.
IMPRESSION:
1. A lower anterior abdominal wall peripherally enhancing fluid collection
containing locules of air is decreased in size from prior, currently measuring
up to 9.6 cm, compared with 14.2 cm previously, however is again concerning
for infected seroma/abscess. This would be amenable to percutaneous drainage
if desired.
2. A 2.7 cm left adrenal lesion is not significantly changed from prior,
however is again incompletely characterized. Recommend correlation with prior
imaging if available, or outpatient MRI/CT adrenal for further
characterization if no prior imaging is available.
3. Hepatic steatosis.
RECOMMENDATION(S): Recommend correlation with prior imaging if available, or
outpatient MRI/CT adrenal for further characterization of a left adrenal
lesion if no prior imaging is available.
Radiology Report
INDICATION: ___ year old woman with postop cellulitus and recurrent abscess
currently receiving IV antibioitcs// assess PICC placement
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal shadow is normal. No airspace consolidation. No suspicious
pulmonary nodules or masses. No pleural effusions. No pulmonary edema.
Right-sided PICC line in situ with the tip at the cavoatrial junction. No
right-sided pneumothorax.
IMPRESSION:
Right-sided PICC line at the appropriate position.
Radiology Report
EXAMINATION: Ultrasound-guided collection drainage.
INDICATION: ___ year old woman with history of post-operative lower abdominal
fluid collection s/p drainage, now readmitted with likely re-accumulation of
cellulitis/ lower abdominal fluid collection.// characterization of lower
abdominal subcutaneous fluid collection, drainage of this collectio
COMPARISON: CT abdomen and pelvis ___
PROCEDURE: Ultrasound-guided drainage of an anterior abdominal wall
collection.
OPERATORS: Dr. ___ Dr. ___ trainees and Dr. ___,
___ radiologist. Dr. ___ supervised the trainee during
the key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via ultrasound.
Approximately 60 cc of cloudy fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Lidocaine local anesthesia only.
FINDINGS:
Intraprocedural sonographic images re-demonstrate a large, complex collection
in the subcutaneous tissues of the anterior abdominal wall. Postprocedure
images demonstrate appropriate positioning of the pigtail catheter within the
collection.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
collection. Sample was sent for microbiology evaluation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abscess
Diagnosed with Cellulitis of abdominal wall
temperature: 97.8
heartrate: 100.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 86.0
level of pain: 10
level of acuity: 3.0 | On ___, Ms. ___ was admitted to the Gynecology service
for pelvic subcutaneous fluid collection concerning for abscess
vs. seroma. CT scan showed "1. A lower anterior abdominal wall
peripherally enhancing fluid collection containing locules of
air is decreased in size from prior, currently measuring up to
9.6 cm, compared with 14.2 cm previously, however is again
concerning for infected seroma/abscess. This would be amenable
to percutaneous drainage if desired. 2. A 2.7 cm left adrenal
lesion is not significantly changed from prior, however is again
incompletely characterized. Recommend correlation with prior
imaging if available, or outpatient MRI/CT adrenal for further
characterization if no prior imaging is available. 3. Hepatic
steatosis." She was initially continued on her home antibiotics,
IV daptomycin and oral doxycycline. She was given IV dilaudid
and tylenol for pain. She remained afebrile with normal vital
signs, and labs initially demonstrated a mild leukocytosis of
12.5. She underwent ___ drainage of the pelvic
subcutaneous fluid collection, during which 60cc of cloudy fluid
was drained and a pigtail catheter was placed for continuous
drainage. Fluid gram stain was negative, with sparse
enterococcus growth, and fluid creatinine were normal, no
anaerobes or acid-fast bacilli were seen. She was seen by the
Infectious Disease team who recommended transitioning to IV
flagyl and ceftazapime, with continuation of her IV daptomycin.
She experienced some urinary urgency, and had a UA which was
normal, and UCx negative. She was given pyridium for her
symptoms. For her type 2 diabetes, her home metformin and
glipizide were held, and she was placed on an insulin sliding
scale and her blood glucose was closely monitored. For her
bipolar disorder, and COPD/asthma, she was continue on her home
medications.
From ___, she continued to improve clinically. Drain
output was 50cc daily. She continued to have no leukocytosis and
no bandemia. She remained afebrile. Her abdominal exam was also
noted to improve with decreasing erythema and induration.
On ___, her CBC was noted to have an HCT drop from 35.6 to
28.6. Her exam was benign with stable VS, low suspicion for
active intraabdominal bleeding. HCT was repeated 6 hours later
and was stable at 36.2. Her drain output also decreased to 30cc.
Due to her clinical improvement, per ID team she was continued
on Daptomycin and transitioned to PO flagyl and levaquin through
___. CRP, CK, ESR were all drawn for daptomycin monitoring
which were all normal. EKG was also obtained which did not show
any evidence of QTc prolongation. She was also restarted on her
home metformin and glipizide. Her ___ remained stable between
130-200.
By ___, she had improved clinically and was discharged to
home in stable condition with home nursing set up for IV ABX
infusion as well as drain care and outpatient follow-up as
scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
New DLBCL
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ F with ___ biopsied Right neck &
Left upper forehead mass. Oncology fellow was called by
Pathology
regarding her tissue biopsy returning as DLBCL.
She reports a history of 'large cell lymphoma in her abdomen' in
___ for which she received 6 cycles of CHOP ('was clean after
5'). She had drenching night sweats at that time.
Currently, she feels well and denies fevers, chills, night
sweats, unintentional weight loss. She has npo SOB or CP at this
time. No other sx per pt.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
History of 'large cell lymphoma in her abdomen' in ___ for
which she received 6 cycles of CHOP
PAST MEDICAL HISTORY:
-Cataracts
-Retinitis pigmentosa
-Hypertension
-Shingles
-Lymphoma
-Hematuria
-Pylonephritis
-Hypercholesterolemia
-Obesity
-Knee pain
mastoidectomy,
removal of bilateral cataracts.
Social History:
___
Family History:
Brother with sturge weber syndrome
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
General: NAD
VITAL SIGNS: 98.6 PO 178 / 82 90 20 97 Ra
HEENT: Multiple hard nodules in R cervical, Anterior jugular
notch, L preauricular, one in nape of the neck.
CV: RR, NL S1S2 ___ SEM in R and L 2ICS
PULM: CTAB
ABD: BS+, soft, NTND,
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
DISCHARGE PHYSICAL EXAM:
========================
VS- 97.9 PO 127 / 61 68 18 97 RA
General: NAD, well appearing
HEENT: Sclera anicteric, MMM
LYMPH: Multiple firm, non-tender ~1-2cm nodules in R anterior
cervical chain, one on posterior neck, decreased in size and
softer. R supraclavicular with bandage and drain in place from
surgery. Small nodule at R axilla improved in size, softer.
CV: RRR, normal S1, S2. No m/r/g. Port in place w/ minimal
erythema
Lungs: CTAB
Abdomen: Soft, nt, nd
Ext: WWP, 2+ pitting edema b/l lower ankles
Neuro: A&O x3
Pertinent Results:
ADMISSION LABS:
===============
___ 09:16PM BLOOD WBC-6.6 RBC-4.24 Hgb-12.9 Hct-38.3 MCV-90
MCH-30.4 MCHC-33.7 RDW-13.3 RDWSD-44.3 Plt ___
___ 09:16PM BLOOD Neuts-63.9 ___ Monos-9.8 Eos-2.4
Baso-0.5 Im ___ AbsNeut-4.25 AbsLymp-1.50 AbsMono-0.65
AbsEos-0.16 AbsBaso-0.03
___ 09:16PM BLOOD ___ PTT-31.1 ___
___ 09:16PM BLOOD Glucose-114* UreaN-19 Creat-1.0 Na-135
K-3.8 Cl-96 HCO3-25 AnGap-18
___ 09:16PM BLOOD ALT-21 AST-23 LD(LDH)-213 AlkPhos-90
TotBili-0.2
___ 09:16PM BLOOD Albumin-4.6 Calcium-9.9 Phos-3.9 Mg-2.0
UricAcd-7.3*
___ 09:16PM BLOOD HBsAg-Negative HBsAb-Negative
___ 09:16PM BLOOD HIV Ab-Negative
___ 09:16PM BLOOD HCV Ab-Negative
IMAGING/STUDIES:
================
TTE ___:
PRE-BYPASS: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
CT NECK ___:
1. Interval resection of large right supraclavicular mass with
postoperative changes in the resection bed.
2. Multiple soft tissue masses, as detailed above, almost all of
which have increased in size from CT neck ___. The
largest mass is abutting the right sternohyoid muscle at the
level of the thyroid now measures 1.7 x 2.2 x 2.9 cm, previously
measuring 1.2 x 1.4 x 2.4 cm on CT neck ___.
CT CHEST ___:
Multiple subcutaneous soft tissue nodules/lymph nodes, with a
few lymph nodes in the superior chest subcutaneous tissue appear
mildly increased in size compared to prior CT neck done ___.
Suspicious pericardial, pleural (intercostal) and a few internal
mammary lymph nodes, but no pathologically enlarged superior
mediastinal lymph nodes.
No conclusive findings to suggest pulmonary involvement.
Moderate aortic valve calcification. Mild coronary artery
calcification.
CT ABD/PELV ___:
1. Numerous soft tissue nodules within the subcutaneous fat and
anterior
abdominal wall measure up to 18 x 9 mm as described in the
findings. These are uncertain in etiology, possibly
lymphomatous. However, alternative etiologies such as melanoma
should be considered. Recommend percutaneous sampling.
2. No splenomegaly or lymphadenopathy in the abdomen or pelvis.
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-5.2 RBC-3.47* Hgb-10.4* Hct-29.7*
MCV-86 MCH-30.0 MCHC-35.0 RDW-13.2 RDWSD-41.6 Plt ___
___ 12:00AM BLOOD Neuts-92.7* Lymphs-6.3* Monos-0.4*
Eos-0.0* Baso-0.0 Im ___ AbsNeut-4.85 AbsLymp-0.33*
AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD ___ PTT-25.4 ___
___ 12:00AM BLOOD Glucose-136* UreaN-27* Creat-0.8 Na-130*
K-3.6 Cl-97 HCO3-21* AnGap-16
___ 08:03AM BLOOD Na-132*
___ 12:00AM BLOOD ALT-28 AST-18 LD(LDH)-180 AlkPhos-58
TotBili-0.3
___ 12:00AM BLOOD TotProt-5.7* Albumin-3.6 Globuln-2.1
Calcium-8.5 Phos-2.7 Mg-2.0 UricAcd-4.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth BID: PRN Disp
#*30 Capsule Refills:*0
4. Dronabinol 2.5 mg PO BID
RX *dronabinol 2.5 mg 1 capsule(s) by mouth BID: PRN Disp #*30
Capsule Refills:*0
5. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide [Anti-Diarrheal (loperamide)] 2 mg 1 tablet by
mouth QID: PRN Disp #*30 Capsule Refills:*0
6. LORazepam 0.5-1 mg PO QHS:PRN insomnia
RX *lorazepam [Ativan] 0.5 mg ___ tablet by mouth qhs: PRN Disp
#*15 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8h: PRN Disp #*30
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth qday:
PRN Disp #*10 Packet Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth qday Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
============================
-Diffuse large B-cell lymphoma
Secondary Diagnosis:
===========================
-Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman with hx of Lymphoma, new R neck mass biopsy of
which showed DLBCL.// For expedited staging. History notable for excision of
right neck and left upper forehead mass positive for dL BCL
TECHNIQUE: Imaging was performed after administration of ml of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 34.4 cm; CTDIvol = 7.1 mGy (Body) DLP = 238.2
mGy-cm.
Total DLP (Body) = 238 mGy-cm.
COMPARISON: CT neck ___
FINDINGS:
Since ___, there has been interval resection of the large right
supraclavicular mass. There is fatty stranding, subcutaneous edema, and foci
of air in the resection bed all of which are likely postoperative changes.
Abutting the right sternal hyoid muscle at the level of the thyroid, , there
is a enhancing soft tissue mass measuring 1.7 x 2.2 x 2.9 cm (AP by TV by CC,
2:61, 5:42), increased in size from CT neck ___, previously measuring
1.2 x 1.4 x 2.4 cm. Abutting the trapezius muscle, there is a enhancing soft
tissue mass which measures 1.1 x 2.2 x 1.5 cm (AP by TV by CC, 2:40, 5:29)
increased in size from ___, previously measuring 1.2 x 1.9 x 1.0 cm.
There is a soft tissue mass at the posterior midline at the C3 level which
measures 1.9 x 1.3 cm (02:39), decreased from ___, previously
measuring 1.3 x 1.1 cm. There is a smaller adjacent soft tissue nodule
measuring 0.7 x 0.6 cm, grossly unchanged from ___. There is a soft
tissue nodule abutting the right sternocleidomastoid muscle measuring 1.5 x
1.2 cm (02:40), increased from ___, previously measuring 1.3 x 1.1
cm. There is a nodule in the right breast (2:80) which is partially
visualized but appears larger in size from ___.
Neck vessels are patent.The imaged portion of the lung apices are clear and
there are no concerning pulmonary nodules. There are no osseous lesions.
IMPRESSION:
1. Interval resection of large right supraclavicular mass with postoperative
changes in the resection bed.
2. Multiple soft tissue masses, as detailed above, almost all of which have
increased in size from CT neck ___. The largest mass is abutting the
right sternohyoid muscle at the level of the thyroid now measures 1.7 x 2.2 x
2.9 cm, previously measuring 1.2 x 1.4 x 2.4 cm on CT neck ___.
Radiology Report
EXAMINATION: CT abdomen/pelvis
INDICATION: ___ year old woman with hx of Lymphoma, new R neck mass biopsy of
which showed DLBCL.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 17.5 s, 0.2 cm; CTDIvol = 297.6 mGy (Body) DLP =
59.5 mGy-cm.
3) Spiral Acquisition 10.4 s, 67.4 cm; CTDIvol = 8.9 mGy (Body) DLP = 596.8
mGy-cm.
Total DLP (Body) = 658 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is not visualized.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Renal cysts measure up to 12 mm on the right and 18 mm on the left. Some
hypoattenuating lesions are too small to completely characterize, but likely
reflect additional cysts. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is a small periampullary
duodenal diverticulum. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are within normal
limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is anteverted. The adnexae are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted. Incidental note is made of an accessory inferior right hepatic
vein.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is grade 1 anterolisthesis of L4 on L5. Small sclerotic lesions in the
pelvis likely reflect bone islands.
SOFT TISSUES: Scattered soft tissue nodules throughout the subcutaneous
tissues are uncertain in etiology (series 4, image 50, 54, 55, 58, 60, 70, 82,
84, 100, 105). Additional nodules are located within the anterior abdominal
wall adjacent to the rectus abdominus musculature (series 4, images 52, 65,
74, 82, 90). The largest nodule in the superior anterior abdominal wall
measures 18 x 9 mm (series 4, image 52). The largest nodule in the
subcutaneous fat is located just above the gluteal region on the left and
measures 12 x 11 mm (series 4, image 78). Small foci of subcutaneous
emphysema in the anterior abdominal wall presumably reflect medication
injection.
IMPRESSION:
1. Numerous soft tissue nodules within the subcutaneous fat and anterior
abdominal wall measure up to 18 x 9 mm as described in the findings. These
are uncertain in etiology, possibly lymphomatous. However, alternative
etiologies such as melanoma should be considered. Recommend percutaneous
sampling.
2. No splenomegaly or lymphadenopathy in the abdomen or pelvis.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ woman with history of lymphoma, new right neck mass:
Biopsy of which showed diffuse large B-cell lymphoma. Expedited staging.
TECHNIQUE: Contrasted CT neck, chest, abdomen and pelvis.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 17.5 s, 0.2 cm; CTDIvol = 297.6 mGy (Body) DLP =
59.5 mGy-cm.
3) Spiral Acquisition 10.4 s, 67.4 cm; CTDIvol = 8.9 mGy (Body) DLP = 596.8
mGy-cm.
Total DLP (Body) = 658 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Prior neck CT done ___
FINDINGS:
There are numerous subcutaneous soft tissue nodules (lymph nodes) for example
in the right prepectoral area (4, 7) measuring 15 mm in length (previously
measuring 12 mm in length). Small left prepectoral soft tissue nodule/lymph
node currently measuring 9 x 6 mm (previously measuring 6 x 7 mm). Soft
tissue nodule in the lower neck anterior to the right lobe of thyroid (4, 5)
measures 17 mm in diameter (previously 13 mm). Multiple other subcutaneous
soft tissue nodules the largest in the right lateral chest wall measuring 22 x
22 mm. A few subcentimeter axillary lymph nodes.
No suspicious thyroid lesions. Small hiatal hernia. Pericardial lymph node
(4, 43) is enlarged measuring 8 mm in diameter. Few mildly enlarged internal
mammary lymph nodes. Right lower pleural/intercostal lymph node measuring 19
x 8 mm (5, 168). Normal cardiac configuration. No pericardial effusion. No
cardiomegaly. Moderate aortic valve calcification. Mild coronary artery
calcification. The pulmonary artery measures at the upper limits of normal.
No filling defects on this nondedicated study. The esophagus is not patulous.
The airways are patent to the subsegmental level. No bronchiectasis. A
couple of pulmonary micro nodules are nonsuspicious. A couple of small
intrapulmonary lymph nodes. No airspace consolidation. No diffuse lung
disease. No diffuse lung disease.
Spondylotic changes of the thoracic spine. No lytic/destructive bony lesions
concerning for bony involvement.
IMPRESSION:
Multiple subcutaneous soft tissue nodules/lymph nodes, with a few lymph nodes
in the superior chest subcutaneous tissue appear mildly increased in size
compared to prior CT neck done ___.
Suspicious pericardial, pleural (intercostal) and a few internal mammary lymph
nodes, but no pathologically enlarged superior mediastinal lymph nodes.
No conclusive findings to suggest pulmonary involvement.
Moderate aortic valve calcification. Mild coronary artery calcification.
For neck, abdomen and pelvis findings please refer to their respective
reports.
Radiology Report
INDICATION: ___ year old woman with new DLBCL, needs port placement for
chemotherapy// Please place double lumen chest port need both access for
___ aware
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___, attending radiologist, performed
the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 15 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Versed, fentanyl, 1% lidocaine
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.4 min, 2 mGy
PROCEDURE
1. Left internal jugular approach chest double lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short Amplatz wire
was advanced distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The double lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
Prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Steri-Strips were used to close the
venotomy incision site. Steri-Strips were applied over the sutures. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the right atrium.
The both port lumens were accessed using a non coring ___ needle and could
be aspirated and flushed easily. Sterile dressings were applied. The patient
tolerated the procedure well without immediate complication. The port was
left accessed as requested.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a double lumen chest power Port-a-cath via the left
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Oth types of foliclar lymph, nodes of head, face, and neck
temperature: 98.8
heartrate: 104.0
resprate: 17.0
o2sat: 100.0
sbp: 191.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman w/ prior lymphoma in ___
treated w/ 6 cycles CHOP found to have DLBCL admitted for
staging and determination of treatment.
#DLBCL, germinal center type: R supraclavicular mass removed by
plastic surgery with pathology showing follicular lymphoma w/
transformation to DLBCL. Cytogenetics positive for IGH/BCL2 and
rearrangement of BCL6, negative for MYC. Several nodules on R
neck, R axilla, nape of neck, and lower back. Underwent CT
head/neck/torso for staging which showed subcutaneous nodules in
neck, chest, abdomen. Also had TTE given plan for anthracycline
therapy with EPOCH-R which showed no cardiomyopathy (LVEF >55%).
Started on allopurinol to prevent tumor lysis given uric acid
7.8. The patient completed EPOCH-R (5 day cycle), tolerated well
with minimal nausea, and resulting shrinkage of subcutaneous
nodules. Patient to return to clinic on ___ for neulasta, and
again on ___ w/ Dr ___ further management of DLBCL.
#Lower extremity Edema:
#Weight gain: Patient w/ 10 lb increase in weight and
development of lower extremity edema iso prednisone as well as
IV hydration for chemotherapy. Gentle IV diuresis in house with
some improvement. Patient weight on discharge 165.8 (dry weight
157.7). The patient's volume status is expected to improve once
discharged as she will no longer be receiving IVF or pred and
given her good kidney function. Patient to have close follow up
for further management.
#INSOMNIA: Likely iso pred and anxiety. Improved w/
diphenhydramine + ramelteon + lorazepam PRN. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lipitor / Omeprazole / Benicar / alendronate sodium
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ washout, 10cm SBR, re-anastamosis D4-distal jejunum
___ Washout, resection 40cm proximal jejunum
___ Ex-lap, SMA stent, SBR resection
History of Present Illness:
Mr. ___ is an ___ y/o male PMHx of carotid stenosis s/p CEA,
Left femoral endarterectomy and left common iliac artery stent,
claudication, HLD, HTN, DM, CKD III, C diff colitis (___),
pancreatitis ___ ETOH s/p x3 debridements, who presents to ___
after multiple episodes of coffee ground
emesis, nonbloody diarrhea, and increasing abdominal pain
beginning ___. CT abdomen/pelvis obtained while in
ED showed portal venous gas and pneumatosis in the duodenum
and jejunum in concerning for bowel necrosis.
Past Medical History:
- CAD s/p rca stent ___
- DM (IDDM) diagnosed after severe pancreatitis in ___
- Hypercholesterolemia
- Hypertension
- Pancreatitis ___ EtOH s/p 3 debridements for evacuation of
pseudocyst
- S/p rectal fistula repair
- S/p cholecystectomy
- S/p L CEA ___
- PAD w/ LLE claudication & h/o left heel ulcer
- Lymphocytic colitis
- Dysphagia of unknown etiology
- C. diff colitis (___)
Social History:
___
Family History:
No family history of coronary artery disease, diabetes, or
hypertension.
Physical Exam:
Physical Exam: upon admission: ___:
Vitals:T:98.0, HR:100 BP:122/71 RR:30 Sats:99%RA
GEN: In acute distress, unable to redirect,
HEENT: No scleral icterus, mucus membranes moist
CV: Tachycardic, regular rhythm
PULM: Clear to auscultation b/l, tachypneic
ABD: Soft, mildy distended, peritoneal, guarding, multiple
abdominal scars
GU:Foley in place
Ext: No ___ edema, ___ warm and well perfused, ecchymosis left hip
Discharge Physical Exam:
VS:
GEN:
HEENT:
CV:
PULM:
ABD:
EXT:
Pertinent Results:
___ 03:54AM BLOOD WBC-8.4 RBC-2.51* Hgb-7.7* Hct-25.3*
MCV-101* MCH-30.7 MCHC-30.4* RDW-15.9* RDWSD-58.4* Plt ___
___ 04:42AM BLOOD WBC-10.3* RBC-2.75* Hgb-8.4* Hct-27.3*
MCV-99* MCH-30.5 MCHC-30.8* RDW-16.0* RDWSD-57.6* Plt ___
___ 04:14AM BLOOD WBC-20.0* RBC-4.57* Hgb-14.0 Hct-43.1
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.5 RDWSD-44.5 Plt ___
___ 04:14AM BLOOD Neuts-82* Bands-4 Lymphs-3* Monos-11
Eos-0* Baso-0 NRBC-0.2* AbsNeut-17.20* AbsLymp-0.60*
AbsMono-2.20* AbsEos-0.00* AbsBaso-0.00*
___ 06:16AM BLOOD ___ PTT-29.8 ___
___ 03:54AM BLOOD Glucose-113* UreaN-33* Creat-0.5 Na-141
K-3.7 Cl-109* HCO3-26 AnGap-6*
___ 04:42AM BLOOD Glucose-133* UreaN-30* Creat-0.6 Na-137
K-4.0 Cl-110* HCO3-22 AnGap-5*
___ 11:58AM BLOOD ALT-103* AST-17 LD(LDH)-282* AlkPhos-124
TotBili-0.9
___ 04:14AM BLOOD ALT-153* AST-201* AlkPhos-152*
TotBili-2.0*
___ 01:21AM BLOOD cTropnT-0.15*
___ 01:38PM BLOOD CK-MB-4 cTropnT-0.16*
___ 04:35AM BLOOD cTropnT-0.14*
___ 03:54AM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9 Iron-23*
___ 03:54AM BLOOD calTIBC-135* VitB12-852 Ferritn-505*
TRF-104*
___ 11:58AM BLOOD Triglyc-65
___ 03:47AM BLOOD freeCa-1.23
IMAGING:
___: CT Abdomen/Pelvis:
1. Extensive portal venous gas and pneumatosis in the duodenum
and long
segment of the jejunum in the right abdomen which is
nonenhancing and highly concerning for bowel necrosis. No
pneumoperitoneum. No central occlusion of the mesenteric
arteries although there is severe atherosclerotic calcification
and narrowing at their origin in both the celiac axis, SMA, and
their branches. The ileum and colon appears spared.
2. Heterogeneous hepatic parenchyma with areas of
hypoenhancement in the right hepatic lobe which could suggest
infarction.
3. Distended stomach with fluid-filled dilated partially
visualized thoracic esophagus putting the patient at risk for
aspiration.
4. Trace aspiration or mild atelectasis in the left lung base.
___: KUB:
Intraoperative images were obtained during retrograde stenting
of a proximal SMA stenosis. Please refer to the operative note
for details of the procedure.
___: ECHO:
LEFT ATRIUM (LA)/PULMONARY VEINS: Normal LA volume index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Normal RA
size.
LEFT VENTRICLE (LV): Normal wall thicknesses. Normal cavity
size. Cannot exclude regional
systolic dysfunction. No ventricular septal defect. No resting
outflow tract gradient. Indeterminate
diastolic function.
RIGHT VENTRICLE (RV): Normal cavity size. Normal free wall
motion.
AORTIC VALVE (AV): Valve not well seen. No stenosis. No
regurgitation.
MITRAL VALVE (MV): Mildly thickened leaflets. No systolic
prolapse. Moderate MAC. Mild
chordal thickening. Trivial regurgitation. Regurgitation
severity could be UNDERestimated due to
acoustic shadowing.
PULMONIC VALVE (PV): Normal leaflets. Physiologic regurgitation.
TRICUSPID VALVE (TV): Normal leaflets. Physiologic
regurgitation. Normal pulmonary artery
systolic pressure.
PERICARDIUM: Very
___: Dx Portable PICC:
Right PICC line tip is at the cavoatrial junction. NG tube tip
is in the
stomach. Left internal jugular line tip is at the left
brachycephalic vein
and does not reach SVC. It
Bilateral pleural effusions are small on the right and moderate
on the left.
No appreciable pneumothorax. No pulmonary edema.
___: CT Abdomen/Pelvis:
1. Patient is status post surgery for mesenteric ischemia, with
an anastomosis
of the distal duodenum to the distal jejunum. There is a large
nonspecific
loculation of fluid located in the anterior aspect of the
abdominal cavity
with an air-fluid level. No evidence of extraluminal contrast.
2. Newly developed fractures including a wedge fracture of T12
and a fracture
of the posterior element of T11.
3. Dense material located in the hilum of the liver, likely
reflux of oral
contrast into the biliary system. Correlate clinically.
4. Small bilateral pleural effusions.
___: Procedure:
Successful US-guided drainage of serosanguineous abdominal
collection. Sample
was sent for microbiology evaluation.
___: Procedure:
Successful placement of a 18 ___ MIC gastrojejunostomy tube
with its tip in
the proximal jejunum past the anastamosis. The gastric port
should not be used
for 24 hours.
___: CT Chest:
Widespread broncho pneumonia, right lower and left upper lobes.
Collapsed left lower lobe.
Severe compression fracture, T12 vertebral body. If there is
concern about
neurologic compromise, MRI should be obtained.
___: CT Abdomen/Pelvis:
1. Contrast administered through the gastrojejunostomy tube
passes into the
colon with no evidence of leak.
2. Interval decrease in size of a thin rim enhancing loculated
fluid
collection in the anterior abdomen as well as a small amount of
free air,
consistent with resolving postsurgical collections. This
collection is more
organized compared to the prior exam.
3. Small left pleural effusion is not significantly changed,
right pleural
effusion is decreased in size.
4. Small consolidation at the right lung base is likely due to
aspiration.
___: RUE US:
No evidence of deep vein thrombosis in the right upper
extremity.
___: Procedure:
Successful US-guided placement of ___ pigtail catheter into
the
collection. Samples was sent for microbiology evaluation.
___: G/GJ/GI TUBE CHECK PORT:
No evidence of leak identified after the administration of
water-soluble
contrast through the gastrojejunostomy tube.
___: CXR:
In comparison with the study of ___, there are improved lung
volumes.
Cardiomediastinal silhouette is stable. There has been some
improvement in the substantial pulmonary edema, much of which
could merely reflect the
improved lung volumes. In asymmetric opacification in the left
mid to lower lung is again seen. In the appropriate clinical
setting, this would raise the possibility of
aspiration/pneumonia. Obscuration of the left hemidiaphragm with
retrocardiac opacification is consistent with pleural fluid and
volume loss in left lower lobe.
MICROBIOLOGY:
___ 6:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>___ R
VANCOMYCIN------------ 1 S
Medications on Admission:
1. Acetaminophen 650 mg PO 5X/DAY
2. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
for 4 weeks
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcu once a day Disp #*28
Syringe Refills:*0
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. NPH 23 Units Breakfast
NPH 10 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
10. Rosuvastatin Calcium 10 mg PO QPM
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheeze
2. LORazepam 0.5-1 mg IV Q4H:PRN anxiety/agitation
3. Morphine Sulfate ___ mg IV Q4H:PRN Pain/Dyspnea
4. Ondansetron ___ mg IV Q8H:PRN Nausea/Vomiting - First Line
5. OxyCODONE (Immediate Release) 2.5 mg NG Q6H:PRN Pain -
Moderate
6. QUEtiapine Fumarate 25 mg PO QAM
7. QUEtiapine Fumarate 25 mg PO Q6H:PRN agitation
8. QUEtiapine Fumarate 50 mg PO QHS
9. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
10. Scopolamine Patch 1 PTCH TD ONCE Duration: 72 Hours
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
small bowel necrosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with abdominal pain and concern for perf// eval for
free air
TECHNIQUE: Chest AP
COMPARISON: Lungs are moderately well expanded with platelike atelectasis
versus trace aspiration in the lung bases. No pulmonary edema or
consolidation concerning for pneumonia. Cardiomediastinal silhouette and hila
are normal. No pneumothorax or pleural effusion.
No evidence of pneumoperitoneum. Portal venous gas overlying the liver is far
better appreciated on subsequent abdominal CT.
FINDINGS:
1. No evidence of pneumoperitoneum.
2. Portal venous gas overlying the liver is far better appreciated on
subsequent abdominal CT.
3. Atelectasis versus trace aspiration in the lung bases.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with diffuse abd pain, N/VNO_PO
contrast// eval for intra-abdominal process
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 7.3 s, 57.6 cm; CTDIvol = 14.0 mGy (Body) DLP = 806.9
mGy-cm.
Total DLP (Body) = 825 mGy-cm.
COMPARISON: CT of the abdomen and pelvis from ___.
Fluoroscopic images from left hip nailing from ___.
CT pelvis from ___.
FINDINGS:
LOWER CHEST: Mild left basilar opacity suggests atelectasis and possibly trace
aspiration. Thoracic esophagus is distended and fluid-filled. Severe
coronary artery calcifications. No pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is extensive diffuse portal venous gas. Visualized
parenchyma is heterogeneous specially hypoattenuating right hepatic lobe and
hepatic dome. No evidence of focal lesion. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is
surgically absent.
PANCREAS: Severely atrophic and fatty replaced. No evidence of focal lesions
or peripancreatic stranding.
SPLEEN: The spleen shows normal size, without evidence of focal lesions.
Heterogeneity is likely due to contrast mixing.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of hydronephrosis. Both kidneys contain numerous small
hypodensities which are too small to characterize but suggestive of cysts.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is distended. There is extensive diffuse
pneumatosis involving the duodenum and very long segment of jejunum which is
dilated and demonstrates nonenhancing wall compatible with bowel necrosis.
Ileum and colon appear spared. There is no pneumoperitoneum to suggest
perforation. There is trace mesenteric edema in the right upper quadrant. No
drainable fluid collection E. the appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not severely enlarged and contains
calcifications.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: Patent aorta. There is severe atherosclerotic calcification in the
abdominal arteries. Notably there is extremely dense calcification at the
origins of the mesenteric arteries which are severely stenosed with multiple
other areas of severe calcification and stenosis in the celiac axis worse than
the SMA although there is contrast visualized in these vessels and there is no
central occlusion. The portal vein, hepatic veins, and IVC are patent. Air
is seen in the SMV.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Severe degenerative changes of the lumbar spine. Severe compression deformity
of T12 vertebral body demonstrates 2 mm of retropulsion, new from ___, likely
subacute as suggested by sclerosis, without soft tissue changes to suggest it
is acute. Chronic T11 spinous process fracture. Post left proximal femur
ORIF with gamma nail and transfemoral screw with redemonstrated code
trochanteric fracture.
SOFT TISSUES: Mild anasarca. No drainable fluid collection.
IMPRESSION:
1. Extensive portal venous gas and pneumatosis in the duodenum and long
segment of the jejunum in the right abdomen which is nonenhancing and highly
concerning for bowel necrosis. No pneumoperitoneum. No central occlusion of
the mesenteric arteries although there is severe atherosclerotic calcification
and narrowing at their origin in both the celiac axis, SMA, and their
branches. The ileum and colon appears spared.
2. Heterogeneous hepatic parenchyma with areas of hypoenhancement in the right
hepatic lobe which could suggest infarction.
3. Distended stomach with fluid-filled dilated partially visualized thoracic
esophagus putting the patient at risk for aspiration.
4. Trace aspiration or mild atelectasis in the left lung base.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:21 am, immediately after
discovery of the findings. Findings subsequently discussed with the surgical
team in person, who plan on taking the patient to the operating room
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY)
INDICATION: ___ male with bowel ischemia undergoing exploratory
laparotomy and retrograde superior mesenteric artery stenting.
TECHNIQUE: Fluoroscopic images were obtained intraoperatively.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
14 intraoperative images were acquired without a radiologist present.
Images show retrograde cannulation of the superior mesenteric artery and
passage of a wire through a proximal area of stenosis, followed by balloon
dilatation and stent placement. Contrast injection after the intervention
demonstrating recanalization of the proximal SMA stenosis..
IMPRESSION:
Intraoperative images were obtained during retrograde stenting of a proximal
SMA stenosis. Please refer to the operative note for details of the
procedure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p intubated// Eval ETT
COMPARISON: Chest radiograph ___
FINDINGS:
Portable AP view of the chest provided.
Endotracheal tube terminates in the right mainstem bronchus. A left internal
jugular line likely terminates at the junction of the left internal jugular
and brachiocephalic veins. Enteric tube passes into the expected location
stomach beyond the field of view of the image. Lung volumes are low. Patchy
bibasilar opacities likely reflect atelectasis, unchanged. No pleural
effusion or pneumothorax. Cardiomediastinal silhouette is within normal
limits.
IMPRESSION:
Endotracheal tube terminates in the proximal right mainstem bronchus.
Recommend retracting.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 2:47 pm, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ischemic gut// enteric tube placed
correctly?
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiographs ___.
IMPRESSION:
The endotracheal tube terminate 5.4 cm above the carina. Advancement by 2 cm
is recommended. There has been interval placement of an enteric tube which
terminates in the body of the stomach. A left internal jugular Swan-Ganz
catheter terminates in the distal left brachiocephalic vein.
There are small bilateral pleural effusions with bibasilar atelectasis. There
is mild pulmonary edema. There is no focal consolidation or pneumothorax.
The cardiomediastinal silhouette is stable in appearance. There are no acute
osseous abnormalities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ischemic bowel, moving towards extubation
soon// please evaluate lung fields
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
The endotracheal tube terminates 5.1 cm above the carina. A an enteric tube
crosses the diaphragm and terminates outside of the field of view.
Hazy bibasilar opacities are unchanged from prior study most likely represent
trace pleural effusions. There is no focal consolidation, pulmonary edema or
pneumothorax. The cardiomediastinal silhouette is normal in appearance.
There is central pulmonary vascular congestion without overt pulmonary edema.
No acute osseous abnormalities are identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ischemic bowel s/p SMA stenting and removal
of small bowel x2; now with closed abdomen.// ICU CXR
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are stable, as is the cardiomediastinal silhouette. Mild elevation of
pulmonary venous pressure with bilateral layering pleural effusions and
compressive atelectasis at the bases.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with Right PICC// Right PICC 39cm, ___ ___
Contact name: ___: ___ Right PICC 39cm, ___ ___
IMPRESSION:
Right PICC line tip is at the cavoatrial junction. NG tube tip is in the
stomach. Left internal jugular line tip is at the left brachycephalic vein
and does not reach SVC. It
Bilateral pleural effusions are small on the right and moderate on the left.
No appreciable pneumothorax. No pulmonary edema.
Radiology Report
EXAMINATION: Single-contrast upper GI
INDICATION: ___ year old man s/p ex-lap, small bowel resection, SMA stenting
on ___// ? anastomosis open
TECHNIQUE: Single contrast upper GI.
DOSE: Acc air kerma: 28.6 mGy; Accum DAP: 719.56 uGym2; Fluoro time: 11.3
minutes
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Water-soluble contrast (Optiray) was administered with the patient supine.
Contrast opacified the stomach with no significant passage into the duodenum
despite advancement of the tube and repositioning of the patient. After
ejection of approximately 250 cc of Optiray, the patient was noted to be
aspirating at which point the nasogastric tube with set to suction a nasal
cannula was applied. A ___ feeding tube was placed into the
stomach and post pyloric advancement was attempted, however was unsuccessful
due to a closed pylorus.
A small amount of water-soluble contrast passed through the pylorus,
demonstrating two duodenal diverticula. The anastomotic site at the ligament
of Treitz was not visualized.
IMPRESSION:
1. The anastomotic site was not visualized due to poor transit of the injected
contrast into the duodenum with resultant back up and gastroesophageal reflux
and patient aspiration, which required suction and induction of oxygen
therapy.
2. A ___ feeding tube was placed within the stomach as it could
not be advanced past the pylorus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___
p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR,
anastomosis D4 to distal jejunum, abd closed// possible aspiration
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right PICC line projects over the upper right atrium,
approximately 2 cm beyond the cavoatrial junction. 2 tubes project over the
expected location of the esophagus. Dense contrast material is seen within
the stomach.
There are new dense branching opacities in the medial lower lungs bilaterally,
likely reflecting aspirated Optiray from today's upper GI study. Superimposed
pneumonia would be hard to exclude. There is no pneumothorax or large pleural
effusion. The size of the cardiomediastinal silhouette is within normal
limits.
IMPRESSION:
Aspirated Optiray is seen within the lower lungs bilaterally.
Radiology Report
INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___
p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR,
anastomosis D4 to distal jejunum, abd closed. Please evaluate for possible
obstruction// possible obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT dated ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Oral contrast
material is seen within the distal small bowel, ascending colon and proximal
transverse colon. 2 enteric tubes project over the stomach.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
Osseous structures are notable for orthopedic hardware in the proximal left
femur.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No evidence of a small bowel obstruction. Oral contrast material is seen
within the distal small bowel and proximal colon.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with aspiration of contrast// lung fields
lung fields
IMPRESSION:
Comparison to ___. The lung volumes are normal. Moderate
cardiomegaly without evidence of pulmonary edema. Retrocardiac atelectasis,
right basilar atelectasis, likely presence of a small left pleural effusion.
The course of the feeding tubes and the position of the right PICC line are
stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p ex lap and SBR with aspiration of PO
contrast// lung fields lung fields
IMPRESSION:
Comparison to ___. No relevant change is noted. 1 of the feeding
tubes was removed. The second feeding tube is in stable position. Stable
position of the right PICC line. Minimal decrease in severity of the
bilateral parenchymal atelectasis, the extent of the mild to moderate pleural
effusions is unchanged. No evidence of pulmonary edema. Borderline size of
the cardiac silhouette.
Radiology Report
INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___
p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR,
anastomosis D4 to distal jejunum, abd closed// eval for obstruction,
progression of contrast
TECHNIQUE: Portable AP supine radiograph of the abdomen and pelvis
COMPARISON: ___
FINDINGS:
All the oral contrast now appears to be within the colon. There is a paucity
of small bowel gas. The colon is not dilated. NG tube is seen within the
stomach.
No evidence of free air on this supine radiograph.
Incidental note is made of calcification of the vas deferens. A wound VAC is
noted. Visualized portions of the left femoral gamma nail intramedullary rod
have the expected appearance.
IMPRESSION:
No evidence of obstruction with passage of oral contrast completely into the
colon.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old man s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm
SBR, anastomosis D4 to distal jejunum, abd closed// evaluate for anastomotic
stricture- oral contrast only (do NOT use IV contrast)
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 54.2 cm; CTDIvol = 19.0 mGy (Body) DLP =
1,030.6 mGy-cm.
2) Sequenced Acquisition 0.5 s, 16.0 cm; CTDIvol = 6.3 mGy (Body) DLP =
101.4 mGy-cm.
Total DLP (Body) = 1,132 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
LOWER CHEST: There are bilateral pleural effusions measuring 28 mm on the left
and 26 mm on the right. There are mild atelectatic changes in both lung bases.
ABDOMEN:
HEPATOBILIARY: Liver demonstrates a 5 x 2 cm (series 2, image 5) hypodense
area, could represent subcapsular fluid in an area of previous liver
concavity.
there is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
Dense material is seen in the hepatic hilum, likely some oral contrast that
refluxed in the biliary system.
PANCREAS: The pancreas is severely atrophic and not well assessed on this
unenhanced study. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. Bilateral renal cysts
are seen, including a dense 8 mm cyst, likely hemorrhagic. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: An enteric tube is seen with its tip in the stomach. The
patient is status post anastomosis of the distal duodenum to the distal
jejunum. There is no evidence of extraluminal contrast. The small bowel
loops are nondilated. The walls of the colon are less thickened than on prior
study and there is no pneumatosis. There is a large lenticular loculation of
air and fluid level measuring 26.8 cm x 7.4 cm, located at the anterior aspect
of the abdomen, slightly inferiorly to the level of the stomach.
PELVIS: The urinary bladder contains air and a Foley catheter. The distal
ureters are unremarkable.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. A stent is seen in the SMA.
BONES: There is no evidence of worrisome osseous lesions. There is recent
left hip pinning, a newly developed wedge fracture involving the T12 as well
as the posterior elements of T11. There are also fractures involving the left
lower ribs, these were present previously. There is multilevel degenerative
changes.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Patient is status post surgery for mesenteric ischemia, with an anastomosis
of the distal duodenum to the distal jejunum. There is a large nonspecific
loculation of fluid located in the anterior aspect of the abdominal cavity
with an air-fluid level. No evidence of extraluminal contrast.
2. Newly developed fractures including a wedge fracture of T12 and a fracture
of the posterior element of T11.
3. Dense material located in the hilum of the liver, likely reflux of oral
contrast into the biliary system. Correlate clinically.
4. Small bilateral pleural effusions.
Radiology Report
INDICATION: ___ year old man, s/p exp lap, SMA stent, SBR, ngt tube in place//
please check for placement of NGT
TECHNIQUE: Single portable upright AP view of the upper abdomen is provided.
COMPARISON: Chest and abdominal radiographs ___
FINDINGS:
No dilated loops of bowel to suggest obstruction.
Likely small bilateral pleural effusions. Mild bibasilar atelectasis is
improved compared to ___. There is no pneumothorax. The
cardiomediastinal silhouette is at the upper limits of normal, unchanged. A
righted sided PICC line terminates at the low SVC. Nasogastric tube is again
seen coiled within the stomach.
IMPRESSION:
1. Nasogastric tube overlies the stomach.
2. Improved mild bibasilar atelectasis.
Radiology Report
EXAMINATION: Ultrasound-guided drainage.
INDICATION: ___ year old man s/p exp lap, SMA stent, SBR, now with ant.
loculated abdominal fluid collection// requesting drainage of abdominal fluid
collectcion
COMPARISON: CT abdomen and pelvis dated ___.
PROCEDURE: Ultrasound-guided drainage of abdominal collection.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ supervised the trainee during the
key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via ultrasound.
Approximately 900 cc of serosanguineous fluid was drained with a sample sent
for microbiology evaluation. The ultrasound demonstrated no residual
collection and subsequently the drainage catheter was removed.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was not given.
FINDINGS:
Preprocedural ultrasound of the abdomen demonstrated simple fluid collection
in the abdomen.
IMPRESSION:
Successful US-guided drainage of serosanguineous abdominal collection. Sample
was sent for microbiology evaluation.
Radiology Report
INDICATION: ___ year old man with exp lap, SBR, SMA stenting, continues to
have high NG output, decrease nutritional intake// please place GJ tube past
the Ligament of Treitz
COMPARISON: CT abdomen and pelvis ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___ resident performed the procedure. Dr. ___
supervised the trainee during any key components of the procedure where
applicable and reviewed and agrees with the findings as reported below.
ANESTHESIA: General anesthesia.
MEDICATIONS: 0.5 mg of glucagon IV
CONTRAST: 50 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 31 minutes 8 seconds, 221 mGy
PROCEDURE: 1. Placement of a ___ MIC gastrojejunostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilutecontrast. The needle trajectory
was directed towards the pylorus. In implants wire was introduced and coiled
within the stomach. A small skin incision was made along the needle and the
needle was removed.
A Kumpe catheter was then introduced over the wire and the ___ was
exchanged for a Glidewire.
There was a tight narrowing at the gastrojejunal anastomosis through which the
Glidewire cannot past. The Glidewire was exchanged for an Amplatz, which was
also unsuccessful in crossing the stenosis anastomosis. The Amplatz was
exchanged for a stiff Glidewire and the Kumpe was exchanged for a Sos
catheter. The stiff Glidewire and the RIM catheter were advanced past the
tight narrowing at the gastrojejunal anastomosis. The stiff Glidewire was
then exchanged for an Amplatz wire which is further advanced into the jejunum.
The Sos catheter was removed over the wire. A 16 ___ dilator was used to
dilate the tract. Then, a 22 ___ peel-away sheath was placed over the
wire. A 18 ___ MIC gastrojejunostomy catheter was advanced over the wire
into position. The sheath was then peeled away.
The wire and sheath were removed. The catheter was locked by instilling 7 ml
of dilute contrast into the balloon in the jejunum after confirming the
position of the catheter with a contrast injection. The catheter was then
flushed and capped. Sterile dressings were applied. The patient tolerated the
procedure well and there were no immediate complications.
FINDINGS:
1. Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip
in the jejunum.
2. There was a tight narrowing at the duodenojejunal anastomosis, through
which the distal end of the gastrojejunostomy tube was passed.
IMPRESSION:
Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip in
the proximal jejunum past the anastamosis. The gastric port should not be used
for 24 hours.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with respiratory distress s/p emesis// please
eval for aspiration
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Right-sided PICC line projects to the cavoatrial junction. The NG tube has
been removed. Lungs are low volume with bibasilar atelectasis. Bilateral
effusions have resolved. Cardiomediastinal silhouette is stable. No
pneumothorax is seen
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o male PMHx of carotid stenosis s/p CEA, claudication, HLD,
HTN, DM, CKD III presenting with acute mesenteric ischemia s/p with
retrograde stenting of SMA, open abdomen, 150 cm small bowel resection,
D4-mid jejunal anastomosis, and fascial closure. He is admitted to the ICU for
hypernatremia and need for an insulin gtt. ___ triggered on the floor,
delirious, vomiting bilious and bloody material and WBC increase from 8 to 31.
New left sided retrocardiac and LLL infiltrate. ACS concerned he aspirated.//
daily eval
IMPRESSION:
In comparison with the study of ___, there is engorgement of ill defined
pulmonary vessels consistent with worsening pulmonary edema in this patient
with left lower lobe collapse and left pleural effusion. Area of increased
opacification in the left upper zone was shown to represent a more prominent
area of consolidation than expected merely from the plain radiograph.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___
p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR,
anastomosis D4 to distal jejunum, abd closed// ?anastomosis leak ?vialibility
of abdomen(please give PO contrast through G tube and clamp J tube)
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.6 s, 73.7 cm; CTDIvol = 12.5 mGy (Body) DLP = 917.5
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.7 mGy (Body) DLP =
8.3 mGy-cm.
Total DLP (Body) = 928 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___ and ___, CT
abdomen and pelvis on ___
FINDINGS:
LOWER CHEST: Small left pleural effusion and adjacent atelectasis is similar
to prior. There is a trace right pleural effusion which is decreased in size
from prior. There is a small consolidation at the right lung base likely
representing aspiration. Dense mitral annular calcifications are partially
seen.
ABDOMEN:
HEPATOBILIARY: Heterogeneity of the liver parenchyma is improved from prior,
with minimal residual areas hypodensity at the dome. There is no evidence of
focal lesions.
There is extensive pneumobilia in the left hepatic lobe, likely due to prior
sphincterotomy or incompetent sphincter of Oddi given pneumobilia has been
present since at least ___. There is no portal venous gas. There is no
intrahepatic biliary duct dilatation. Prominence of the common bile duct is
stable from priors and consistent with postcholecystectomy state. The
gallbladder is surgically absent.
PANCREAS: The pancreas is severely atrophic.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are bilateral simple renal cysts measuring up to 3.7 cm in the left
kidney. Multiple additional subcentimeter cortical hypodensities bilaterally
are too small to characterize, however likely represent cysts. There is no
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: GJ tube is present in the stomach, the jejunal limb
terminating in the jejunum left mid abdomen. Patient is status post small
bowel resection. Remaining small bowel loops demonstrate normal caliber.
There is wall thickening of small bowel loops in the anterior abdomen adjacent
to a fluid collection which is reactive (2:70). There is no pneumatosis.
Oral contrast administered through a G-tube passes into the colon with no
evidence of leak. The colon and rectum are within normal limits. The appendix
is normal. Loculation of fluid within the anterior abdomen is decreased in
size from prior, currently spanning 18.5 x 4.8 cm compared with 26.8 x 7.4 cm,
with interval decrease in amount of free air.
PELVIS: A Foley catheter is present in the bladder. The distal ureters are
unremarkable. There is trace free fluid in the pelvis, decreased from prior.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable. There is heavy calcification of the vas deferens bilaterally.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted. Patient is status post SMA stent, with the more distal SMA
appearing patent. There is heavy atherosclerotic calcification at its takeoff
of the celiac axis which appears patent.
BONES: Again noted are old left-sided rib fractures. A compression deformity
of the T12 vertebral body and a fracture of the posterior elements at T11 are
not significantly changed. Multilevel degenerative changes in the lumbar
spine are not significantly changed. Patient is status post gamma nail
fixation of a left femoral fracture. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: There are postsurgical changes along the anterior abdominal
wall. There is diffuse subcutaneous edema.
IMPRESSION:
1. Contrast administered through the gastrojejunostomy tube passes into the
colon with no evidence of leak.
2. Interval decrease in size of a thin rim enhancing loculated fluid
collection in the anterior abdomen as well as a small amount of free air,
consistent with resolving postsurgical collections. This collection is more
organized compared to the prior exam.
3. Small left pleural effusion is not significantly changed, right pleural
effusion is decreased in size.
4. Small consolidation at the right lung base is likely due to aspiration.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ s/p ex-lap x3 for pancreatitis, CAD, IDDM, s/p L hip surg ___
p/w mesenteric ischemia, s/p ex-lap x3, SMA stenting, 108cm + 40 cm +10cm SBR,
anastomosis D4 to distal jejunum, abd closed// ?anastomosis leak ?vialibility
of abdomen(please give PO contrast through G tube and clamp J tube)
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, and/or
followed by scanning of the neck, was reconstructed as contiguous 5 mm and 1.0
or 1.25 mm thick axial, 2.5 or 5 mm thick coronal and parasagittal, and 8 mm
MIP axial images. Concurrent scanning of the abdomen and pelvis and/or neck
will be reported separately. All images of the chest were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.6 s, 73.7 cm; CTDIvol = 12.5 mGy (Body) DLP = 917.5
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.7 mGy (Body) DLP =
8.3 mGy-cm.
Total DLP (Body) = 928 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Compared to chest CT ___
FINDINGS:
CHEST PERIMETER: No thyroid findings need any further imaging evaluation.
Supraclavicular and axillary lymph nodes are not enlarged. No soft tissue
abnormalities in the chest wall. Findings below the diaphragm will be
reported separately.
CARDIO-MEDIASTINUM:Moderate dilatation of the esophagus is long-standing, more
pronounced today than in ___, with retention of the fluid in the upper
esophagus. Findings suggest significant esophageal dysmotility and/or reflux,
rather than mass, but contrast swallow would be required for assessment.
Atherosclerotic calcification is severe in left subclavian artery and
throughout coronary arteries. Aorta and pulmonary arteries are not dilated.
Calcification is extremely heavy in the mitral annulus which predisposes to
mitral regurgitation but left atrium is normal size. Pericardium is
physiologic..
THORACIC LYMPH NODES: As follows:
Thoracic outlet, 11 mm, 2:8, unchanged since ___.
Left upper paratracheal mediastinum, 11 mm, 02:24, 8 mm in ___. Right
posterior paraesophageal mediastinum, 11 mm, 02:34, 8 mm in ___. No
appreciable hilar lymph node enlargement.
LUNGS, AIRWAYS, PLEURAE: Moderate nonhemorrhagic left, and tiny right pleural
effusions layer posteriorly.
Left lower lobe is collapsed; in the absence of bronchial obstruction this is
attributable to the left pleural effusion. Parenchymal abnormalities in the
left lower lobe would not be appreciated.
Extensive bronchiolar nodulation and peribronchial infiltration in the right
lower and left upper lobes is probably multifocal pneumonia.
CHEST CAGE: Severe compression fracture, T12 vertebral body with blastic and
possible lytic components could be pathologic. No obvious retropulsion.
IMPRESSION:
Widespread broncho pneumonia, right lower and left upper lobes.
Collapsed left lower lobe.
Severe compression fracture, T12 vertebral body. If there is concern about
neurologic compromise, MRI should be obtained.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ y/o male PMHx of carotid stenosis s/p CEA, claudication, HLD,
HTN, DM, CKD III presenting with acute mesenteric ischemia s/p with
retrograde stenting of SMA, open abdomen, 150 cm small bowel resection,
D4-mid jejunal anastomosis, and fascial closure. He is admitted to the ICU for
hypernatremia and need for an insulin gtt. ___ triggered on the floor,
delirious, vomiting bilious and bloody material and WBC increase from 8 to 31.
New left sided retrocardiac and LLL infiltrate. ACS concerned he aspiration.
Now new-onset RUE edema.// r/o right upper extremity DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The right basilic,
and cephalic veins are patent, compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION: Left hip radiographs, two views, and pelvis radiograph, single
AP view, portable.
INDICATION: Status post left total hip replacement. Multiple abscesses in
the pelvis. Multifocal pneumonia. Altered mental status.
COMPARISON: CT is available from the prior day.
FINDINGS:
Patient is status post open reduction internal fixation of the left femur with
a gamma nail. Alignment appears normal. No dislocation. Hardware appears
intact without loosening. Hip joint spaces appear preserved in with. Bones
appear demineralized. Vascular calcification is extensive. Each vas deferens
is also calcified.
IMPRESSION:
Status post open reduction internal fixation of the left femur.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with multifocal pneumonia on broad spectrum
antibiotics, fluid overload, abdominal abscesses, SMA stent, and altered
mental status (A Ox1)// eval for interval change
IMPRESSION:
In comparison with the study of ___, the cardiomediastinal silhouette is
stable, as is the degree of pulmonary edema. Opacification at the left base
is consistent with volume loss in left lower lobe and pleural effusion.
Radiology Report
INDICATION: ___ year old man with rim-enhancing superficial anterior abdominal
collection and leukocytosis, concerning for infection// requesting
aspiration/drainage of collection
COMPARISON: Prior CT done ___.
PROCEDURE: Ultrasound-guided drainage of abdominal collection.
OPERATORS: Dr. ___, radiology fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position in his bed in the ward. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, 18G ___ needle was inserted into
the collection. 0.038 ___ wire was placed through the needle and needle
was removed. A sample of fluid was aspirated, confirming needle position
within the collection. This was followed by placement of ___ Exodus
catheter into the collection. The stiffener and the wire were removed.
Pigtail was deployed, and the position of the pigtail was confirmed within the
collection via ultrasound.
Approximately 5 cc of serous fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was not provided
FINDINGS:
Straw-colored serous fluid was aspirated and 5 cc was sent for microbiology
evaluation.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
collection. Samples was sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o male PMHx of carotid stenosis s/p CEA, claudication, HLD,
HTN, DM, CKD III presenting with acute mesenteric ischemia s/p with
retrograde stenting of SMA, open abdomen, 150 cm small bowel resection,
D4-mid jejunal anastomosis, and fascial closure. He is admitted to the ICU for
hypernatremia and need for an insulin gtt. ___ triggered on the floor,
delirious, vomiting bilious and bloody material and WBC increase from 8 to 31.
New left sided retrocardiac and LLL infiltrate. ACS concerned he aspiration.//
daily eval
TECHNIQUE: Portable semi-upright chest AP.
COMPARISON: Chest radiograph from ___
FINDINGS:
There is interval improvement of pulmonary congestion, mainly on the right
side likely due to dependent positioning. Diffuse opacity over the left lung
is not significantly changed. Worsening right lower lobe atelectasis.
Cardiomegaly is unchanged in size.Right PICC line is unchanged.
IMPRESSION:
Diffuse left lung opacities are not significantly changed. Interval
improvement of pulmonary congestion.
Radiology Report
EXAMINATION: G/GJ/GI TUBE CHECK
INDICATION: ___ year old man with GJ tube, found to have bilious drainage
around drain site. Evaluation for gastrojejunostomy tube check.
TECHNIQUE: Scout view of the abdomen was obtained in the AP projection.
Administration of 20 cc of water-soluble contrast was hand injected via the
tube. Postcontrast image of the abdomen was obtained in the AP projection.
COMPARISON: Comparison to CT abdomen/pelvis from ___.
FINDINGS:
A gastrojejunostomy tube is seen projecting over the mid abdomen, with balloon
inflated within the stomach. After the administration of water-soluble
contrast through the tube, a small quantity of contrast is visualized within
the duodenum and jejunum, without evidence of leakage into the abdomen. A
duodenal diverticulum and jejunal diverticulum are incidentally noted.
Small amount of residual enteric contrast is noted within the colon. There is
a nonspecific, nonobstructive bowel gas pattern. A pigtail drainage catheter
projects over the mid abdomen. Few clips are seen projecting over the left
upper quadrant. Partial visualization of surgical fixation hardware within
the left proximal femur.
IMPRESSION:
No evidence of leak identified after the administration of water-soluble
contrast through the gastrojejunostomy tube.
Radiology Report
INDICATION: Emesis, G tube to gravity. Please evaluate for distention.
TECHNIQUE: Portable frontal radiographs of the abdomen and pelvis, compared
with ___.
IMPRESSION:
Gastrostomy tube is again seen, unchanged. Pigtail catheter extending to the
midline abdomen is again seen, similar orientation as the prior. Enteric
contrast is now within the colon.
Bowel gas pattern is unremarkable. No significant bowel distention.
Consolidative opacities seen in the lungs, left greater than right.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new sob and desats after emesis// please
eval for aspiration
TECHNIQUE: Portable chest AP upright.
COMPARISON: Chest radiograph from ___.
FINDINGS:
New right lower and mid lobe focal opacity concerning for aspiration however
may also represent pulmonary edema. Small bilateral pleural effusions no
evidence of pneumothorax. Cardiac silhouette is unchanged. Right PICC line
terminates at the distal SVC.
IMPRESSION:
New right lower and mid lobe opacities may represent aspiration or pulmonary
edema
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with bilateral pulmonary infiltrates s/p
diuresis// please eval for interval change please eval for interval
change
IMPRESSION:
Compared to chest radiographs, ___ through ___ at 05:30.
Upper lobe pulmonary vascular congestion has improved, while bilateral
perihilar opacification has improved on the right, not on the left. This
could be edema, changing in distribution depending on patient positioning, but
the lower lobes are still densely consolidated. Moderate bilateral pleural
effusions are unchanged. No pneumothorax. Heart size is stable, not
appreciably enlarged and mediastinal veins are not engorged.
Right PIC line ends in the mid to low SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p exp lap, SMA stenting with GJ tube, now with
vomiting, coughing// compare interval change
IMPRESSION:
In comparison with the study of ___, there are improved lung volumes.
Cardiomediastinal silhouette is stable. There has been some improvement in
the substantial pulmonary edema, much of which could merely reflect the
improved lung volumes. In asymmetric opacification in the left mid to lower
lung is again seen. In the appropriate clinical setting, this would raise the
possibility of aspiration/pneumonia.
Obscuration of the left hemidiaphragm with retrocardiac opacification is
consistent with pleural fluid and volume loss in left lower lobe.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, n/v/d
Diagnosed with Other specified diseases of intestine, Unspecified abdominal pain
temperature: 96.0
heartrate: 100.0
resprate: 30.0
o2sat: nan
sbp: 122.0
dbp: 71.0
level of pain: 10
level of acuity: 1.0 | Mr. ___ is an ___ year-old male with a history of pancreatitis
c/b pseudocyst and multiple debridements, insulin-dependent DM,
CAD s/p RCA stent, carotid artery stenosis s/p CEA, PAD s/p
stent, HTN, prior alcohol use, recurrent C diff, and lymphocytic
colitis who was admitted to the hospital with vomiting and
abdominal pain. Upon admission, the patient was made NPO, given
intravenous fluids and underwent imaging. A cat scan of the
abdomen/pelvis was obtained which showed portal venous gas and
pneumatosis in the duodenum and jejunum concerning for bowel
necrosis.
Based on these findings, he was taken to the operating room
where he underwent an ex-lap, small bowel resection, and SMA
stenting on ___. After the surgery he was admitted to the
intensive care unit for monitoring. During his stay, he
received blood products (RBCs and FFP) and returned to the
operating room on ___ for primary re-anastomosis and closure of
fascia. He was extubated on ___. On ___, the patient had a
sodium of 151, and was started on D5W and TPN without sodium.
He was transferred to the surgical floor on ___. However, he
returned to the ICU soon after when he was reported to have a
sodium of 158. He continued on D5W and started on an insulin
drip for an elevated blood sugar. Once his hypernatremia
improved, he was transferred back to the surgical floor.
Neurosurgery was consulted for management of his T12 wedge
fracture and recommended a TLSO brace on side of bed for use
when he is out of bed to chair. ___ was consulted for enteral
access and a GJ tube was placed. The G tube was kept to gravity,
and tube feeds were initiated via the J tube. Plavix was started
on ___ for mesenteric stent patency once enteral access was
established.
The patient again returned to the intensive care unit on ___
after he had an acute desaturation event with hematemesis,
concerning for aspiration and possible upper GI bleed. He was
started on broad spectrum antibiotics for presumed aspiration
pneumonia based on his respiratory status, chest xray, and
significant leukocytosis to 30. He initially required
non-rebreather but was weaned to high flow nasal cannula and
eventually to regular nasal cannula. He underwent a CT torso to
evaluate for other infectious sources, which revealed an
anterior abdominal wall collection concerning for abscess. A
drain was placed into the collection by ___ on ___. While in the
ICU, he developed dark red stools and similar output from his G
tube. His hematocrit slowly dropped and he required
transfusions. GI was consulted and recommended a BID IV PPI and
upper endoscopy. Endoscopy was referred, as his hematocrit
eventually stabilized. During his ICU stay, code status was
discussed with the patient's wife, and he was transitioned to
DNR/DNI. The patient was deemed stable for transfer to the
surgical floor on ___.
While on the surgical floor, the patient experienced episodes of
emesis and there was concern for aspiration. Tube feeds were
held and a bowel regimen was given which resulted in a large
bowel movement. He received Lasix for diuresis. His wound vac
was changed and the wound continued to heal well. A family
meeting was held with the surgical team and palliative care and
the decision was made to make the patient's care comfort
measures only. Vitals signs were stopped, diet as tolerated,
and medications provided for pain relief, agitation, and nausea.
He was discharged to ___ to continue providing comfort
care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / bee pollen
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
DISCHARGE EXAM:
CV: RRR
Respiratory: No increased work of breathing
Skin: pink patch on b/l feet with areas of desquamation without
surrounding erythema. Papular rash on arms, chest, back, and
legs
with some areas that appear excoriated, overall improved from
yesterday
NEURO: Fine resting tremor
Psych: Appropriate mood and affect
Labs on admission:
___ 12:07AM BLOOD WBC-9.9 RBC-4.54 Hgb-11.4 Hct-36.7
MCV-81* MCH-25.1* MCHC-31.1* RDW-13.0 RDWSD-37.5 Plt ___
___ 12:07AM BLOOD Neuts-87.6* Lymphs-9.5* Monos-1.8*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-8.62* AbsLymp-0.94*
AbsMono-0.18* AbsEos-0.01* AbsBaso-0.02
___ 12:07AM BLOOD ___ PTT-41.1* ___
___ 12:07AM BLOOD Glucose-203* UreaN-15 Creat-0.7 Na-142
K-4.7 Cl-107 HCO3-19* AnGap-16
___ 12:07AM BLOOD ALT-21 AST-29 LD(LDH)-349* AlkPhos-343*
TotBili-0.3
___ 12:07AM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.8 Mg-1.8
___ 12:07AM BLOOD T4-11.6 Free T4-1.9*
___ 12:07AM BLOOD CRP-95.5*
Interim Labs:
___ 06:58AM BLOOD T3-164 Free T4-1.7
___ 12:07AM BLOOD TSH-<0.01*
MICRO
___ 8:17 pm TISSUE Source: Skin biopsy r/o hsv. RIGHT
FOOT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
TISSUE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___ MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No
Herpes
simplex (HSV) virus isolated.
Blood culture- NGTD x2
Urine culture- Negative
Imaging:
Foot xray:
IMPRESSION:
No evidence of subcutaneous gas of the right or left feet. No
bony erosive changes. No acute fracture or dislocation.
___:
IMPRESSION: ___
No evidence of deep venous thrombosis ___ the right or left lower
extremity veins.
PATHOLOGY:
Prelim Skin biopsy pathology (final pending):
- There are acute and chronic changes.
- Ulceration (appears more c/w excoriation changes) with
impetiginized scale crust (surface bacteria ___ H&E slides).
Stains to look for dermal organisms are pending.
- Pan dermal mixed cell inflammation - eos, neuts, lymphs,
histiocytes.
- Not much epidermis to judge.
- The eos suggest a florid hyp rxn - the depth of inflammation
is
more than usually observed with typical contact dermatitis.
Cant
exclude a "dermal contactant"
- The neuts are somewhat unusual for hyp rxn so and with
background chronic changes with histiocytes cant exclude a
component of resolving cellulitis.
- No vasculitis seen.
- Overall: Question dermal hyp rxn with superimposed, possibly
resolving infection.
- The ulcer really isn't typical of an ischemic ulcer. Has
extruded collagen which we see ___ excoriations and acquired perf
dermatoses (reactive perf collag). Would favor excoriated but
would like to know if she has that hx. Might consider
superimposed acquired perf dermatosis ___ diabetic if she has
more
similar and/or punctate crusted lesions away from this.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 75 mg PO QHS
2. MetFORMIN (Glucophage) 500 mg PO BID
3. amLODIPine 5 mg PO DAILY
4. MethIMAzole 10 mg PO DAILY
5. DULoxetine ___ 60 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth q12 Disp #*13 Tablet Refills:*0
3. Atenolol 50 mg PO DAILY
RX *atenolol 50 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
5. Hydrocortisone Oint 2.5% 1 Appl TP BID Face Rash
RX *hydrocortisone 2.5 % Apply to face and neck twice a day
Refills:*0
6. Mupirocin Ointment 2% 1 Appl TP BID
RX *mupirocin 2 % Apply to open area on top of feet twice a day
Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone [Oxaydo] 5 mg ___ tab by mouth BID PRN Disp #*16
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 dose by
mouth twice a day Disp #*60 Packet Refills:*0
9. Senna 17.2 mg PO QHS
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 3 tab by mouth
at bedtime Disp #*60 Tablet Refills:*0
10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID rash on
trunk and extremites
RX *triamcinolone acetonide 0.1 % Apply to trunk and extremities
twice a day Refills:*0
11. Amitriptyline 75 mg PO QHS
12. amLODIPine 5 mg PO DAILY
13. DULoxetine ___ 60 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. HELD- MethIMAzole 10 mg PO DAILY This medication was held.
Do not restart MethIMAzole until you see your Endocrine doctor
16.Equipment
Rx: Rolling walker
Dx: bilateral lower extremity rash L30.9
Px: good
___: 13 mo
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Contact dermatitis with superimposed infection
#Thyrotoxicosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL BILATERAL
INDICATION: History: ___ with b/l ___ rash // eval for soft tissue gas
TECHNIQUE: Multiple views of the bilateral feet.
COMPARISON: No relevant prior studies available for comparison.
FINDINGS:
Right:
No acute fractures or dislocation are seen. There are no significant
degenerative changes. Tiny plantar calcaneal spur. Mineralization is normal.
There are no erosions. Os peroneus. No evidence of subcutaneous gas.
Left:
No acute fractures or dislocation are seen. There are degenerate changes of
the midfoot, best seen on lateral view. Tiny plantar calcaneal spur.
Mineralization is normal. There are no erosions. Os peroneus. No evidence
of subcutaneous gas.
IMPRESSION:
No evidence of subcutaneous gas of the right or left feet. No bony erosive
changes. No acute fracture or dislocation.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with b/l foot rash. Now with unequal edema R>L.
// ?dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: CT of the abdomen pelvis from ___.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Prominent left-sided groin lymph nodes measuring up to 1.1 cm along the short
axis, unchanged from prior, with normal morphology.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Foot swelling, Rash
Diagnosed with Rash and other nonspecific skin eruption
temperature: 97.5
heartrate: 131.0
resprate: 20.0
o2sat: 99.0
sbp: 187.0
dbp: 90.0
level of pain: 10
level of acuity: 1.0 | SUMMARY:
___ yo F PMHx ___, stage IA serous endometrial adenocarcinoma
s/p abdominal hysterectomy, b/l salpingoopherectomy, adjuvant
chemo and brachytherapy (completed ___, DM2, HTN and eczema
who presents with b/l ___ rash, most likely caused by exuberant
contact dermatitis with MSSA superinfection and subsequent skin
breakdown with associated id reaction on the body ___ the setting
of diffuse xerosis. Hospital course complicated by symptomatic
hyperthyroidism, started on beta blockade with improvement. |
Name: ___ #1 TO ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
The patient is a ___ without ___ medical history who
presented to the ED today complaining of headache. The patient
reports that she previously presented to the ED on ___
complaining of three days of sore throat, migraine-like
headache, nausea, subjective fevers and chills, and body aches.
She did have some C7 point tenderness at the time, but did not
have photophobia or meningeal signs. She was thought to have a
viral syndrome and was discharged after fluid resuscitation. She
represented to the ED today with continuing headache. The
patient notes that her viral symptoms have largely resolved. She
describes a right temporal to frontal headache, ___ at worst,
but currently ___. She notes that it is worse when she is lying
flat than sitting upright. She previously had minimal
photophobia, but is currently without symptoms. The patient
reports that she has had chronic headache similar in quality to
her present headache. She gets these every one to two weeks,
generally aborts with ibuprofen. The difference between this
headache and her usual headaches is the duration (now multiple
days) and the fact that it prevents her from falling asleep. Her
usual headaches are usual accompanied by mild photophobia and
some nausea. She denies vomiting, diplopia, or visual phenomena.
.
In the ED, initial vital signs were 99.2 82 127/76 18 100%. A CT
head was performed which did not demonstrated intracranial
bleed. A lumbar puncture was performed in the ED with a WBC
count of 16 (N6, L90) and RBC 715 which improved to 36 over
subsequent vials. Protein and glucose were normal at 21 and 54,
respectively.
Past Medical History:
No significant past medical history.
Social History:
___
Family History:
Father: DM
Brother/twin sister: asthma
___ sister: anemia
No family history of thrombosis
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 98.4 113/67 96 18 96RA
GEN: AOx3, comfortable-appearing in NAD
HEENT: NCAT, EOMI, anicteric sclera, MMM, OP clear, no sinus
tenderness
NECK: Supple without LAD or thyromegaly
PULM: CTA b/l without wheeze, rhonchi, crackles, or focal
dullness
COR: RRR (+)S1/S2 no m/r/g appreciated
ABD: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly
GU: no foley
EXTREM: Warm and well perfused, 2+ pulses
NEURO: Mentating well, CNII-XII intact by testing, strength ___
x4 extrem, sensation intact, PERRLA, no meningeal signs, no
photophobia
.
PHSYICAL EXAM ON DISCHARGE:
VS: 99.6 99/53 98 18 98
GEN: AOx3, non-toxic and comfortable-appearing in NAD
HEENT: NCAT, EOMI, MMM, OP clear, no sinus tenderness
NECK: Supple without LAD or thyromegaly
PULM: CTA b/l without wheeze, rhonchi, crackles, or focal
dullness
COR: RRR (+)S1/S2 no m/r/g appreciated
ABD: Soft, non-tender, non-distended, bowel sounds present,
EXTREM: Warm and well perfused, 2+ pulses
NEURO: Mentating well, CNII-XII intact by testing, strength ___
x4 extrem, sensation intact, PERRLA, no meningeal signs, no
photophobia
Pertinent Results:
LABS ON ADMISSION:
___ 07:40PM BLOOD WBC-6.0 RBC-4.67 Hgb-13.4 Hct-40.4 MCV-87
MCH-28.8 MCHC-33.2 RDW-12.2 Plt ___
___ 07:40PM BLOOD Neuts-67.3 ___ Monos-6.1 Eos-0.2
Baso-0.4
___ 07:40PM BLOOD Glucose-129* UreaN-5* Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-28 AnGap-12
___ 07:40PM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
.
LABS ON DISCHARGE:
___ 08:37AM BLOOD WBC-5.9 RBC-4.83 Hgb-14.3 Hct-41.8 MCV-87
MCH-29.6 MCHC-34.2 RDW-12.4 Plt ___
___ 08:37AM BLOOD Glucose-81 UreaN-7 Creat-0.9 Na-139 K-4.0
Cl-103 HCO3-29 AnGap-11
.
CSF FINDINGS:
(First tube) ___ 04:45PM CEREBROSPINAL FLUID (CSF) WBC-16
RBC-715* Polys-6 ___ Monos-4
(Tube #2-#4) ___ 04:45PM CEREBROSPINAL FLUID (CSF) WBC-15
RBC-36* Polys-1 ___ ___ 04:45PM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-54
.
IMAGING:
___ CT Head
There is no evidence of acute intracranial hemorrhage, edema,
large
vessel territory infarctions or shift of midline structures.
The ventricles and sulci are normal in size and configuration.
Gray-white matter differentiation is well preserved. No acute
fractures are identified. There is mild ethmoidal and
sphenoidal mucosal thickening; otherwise, the remainder of the
visualized mastoid air cells and paranasal sinuses are clear.
.
___ CXR
The lungs are well expanded and clear. The cardiomediastinal
silhouette, hilar contours, pleural surfaces are normal. There
is no pleural effusion or pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
There were no new medications at the time of discharge. The
patient was recommended to take OTC acetaminophen or NSAIDs +/-
caffeine for headache relief. She was cautioned on limiting her
daily acetaminophen intake to ___ max.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Migraine headache
.
Secondary diagnosis:
Viral syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Cough. Evaluate for pneumonia.
TECHNIQUE: Upright PA and lateral radiographs of the chest.
COMPARISON: None.
FINDINGS: The lungs are well expanded and clear. The cardiomediastinal
silhouette, hilar contours, pleural surfaces are normal. There is no pleural
effusion or pneumothorax.
IMPRESSION: Normal radiograph of the chest.
Radiology Report
HISTORY: Headache.
COMPARISON: None available.
TECHNIQUE: Contiguous axial images were obtained through the brain without
intravenous contrast. Multiplanar reformatted images were prepared and
reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, large
vessel territory infarctions or shift of midline structures. The ventricles
and sulci are normal in size and configuration. Gray-white matter
differentiation is well preserved. No acute fractures are identified. There
is mild ethmoidal and sphenoidal mucosal thickening; otherwise, the remainder
of the visualized mastoid air cells and paranasal sinuses are clear.
IMPRESSION: No acute intracranial injury.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: HEADACHE
Diagnosed with HEADACHE, UNSPEC VIRAL INFECTION
temperature: 99.2
heartrate: 82.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 76.0
level of pain: 10
level of acuity: 3.0 | The patient is a ___ without significant past medical history
who presented to the ED with viral symptoms and headache, s/p LP
with no striking findings on CSF, admitted for symptom control
and concern for aseptic meningitis.
.
#Headache
Patient with headache for past 5 days with viral symptoms
including sore throat, nausea, subjective fever and chills, and
body aches. Viral symptoms largely resolved. Patient reported
that headache was similar in quality to usual headaches (same
location, nausea, mild photophobia), with the only difference
being persistent pain and difficulty falling asleep because of
the pain. In ED, patient afebrile, without meningeal signs, no
bleed on CTH, and CSF with minimal WBC count (possibly accounted
for by RBC ___ traumatic tap), normal protein and glucose. CBC
without leukocytosis. Neuro exam completely non-focal. Current
symptoms seemed most consistent with patient's usual chronic
headache vs. headache ___ viral syndrome vs. rebound headache
from analgesic use. Bacterial meningitis was unlikely given lack
of white cells in CSF. Headaches could still be result of viral
meningitis, though still would expect a larger presence of white
cells. Aseptic meningitis from NSAIDS was possible. History did
not support venous thrombosis given lack of family or personal
history of clot, no OCP use, and no history of smoking.
Positional exacerbation of symptoms could be consistent with
ICP, possibly idiopathic intracranial hypertension given
obesity/overweight, but no concurrent use of tetracyclines,
vitamin A, or OCPs, and no visual symptoms. Unfortunately,
opening pressure of LP not recorded by ED. By the time the
patient reached the floor, her headache was a ___. She was
given some fiorcet for pain relief and offered ondansetron for
nausea. On hospital day #2, the headache had completely
resolved. The patient was encouraged to seek follow-up with her
PCP and request ___ referral to the ___ Headache Center. Final
CSF cultures are negative.
.
TRANSITIONAL ISSUES
#Patient sexually active, and given vague viral symptoms (sore
throat, myalgias, fever, headache), acute HIV syndrome could not
be ruled-out. Patient should obtain HIV testing as an outpatient
in ___ weeks.
#Patient should consider further evaluation of chronic headaches
as a component of her symptoms might be rebound headaches in the
setting of frequent analgesic use. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left long finger pain, r/o flexor tenosynovitis
Major Surgical or Invasive Procedure:
Incision and drainage, flexor sheath, left long finger.
History of Present Illness:
___, RHD, transferred from OSH s/p puncture wound to left
third finger with concern for flexor tenosynovitis. The patient
was doing landscaping 3 days ago, when he must have gotten some
sort of puncture wound to his left third finger, although he
does
not remember the exact trauma. He noticed that the distal finger
tip got swollen that evening and has become progressively
swollen, red, and painful, tracking down his finger, over the
past 2 days. The patient has baseline depression. He states he
has been lying in bed at home because the finger pain has been
so
bad. Denies fevers or chills.
Prior to transfer, patient received Unasyn. Xrays at OSH
negative
for foreign body or fracture. Last meal was last night.
Past Medical History:
depression
Social History:
___
Family History:
NC
Physical Exam:
Exam on hospital discharge:
AVSS
NAD
Left middle finger with incision c/d/i
Mild preincisional erythema
Mild swelling that is much improved compared to initial
presentation
No tenderness along tendon sheath
Long finger not held in flexed position
FPL/EPL/IO intact
SITLT in M/R/U distribution
Exam on presentation to ED:
Left middle finger with 4 positive Kanavel signs. There is a
puncture wound over the finger pad, oozing clear fluid.
Tenderness along the flexor sheath extends to mid palm.
Sensation
intact in all three nerve distributions.
Medications on Admission:
prozac 80'
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. DiphenhydrAMINE 25 mg PO Q6H:PRN itch, insomnia
3. Docusate Sodium 100 mg PO BID
RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
4. Fluoxetine 80 mg PO DAILY
5. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain
RX *Dilaudid 2 mg 1 Tablet(s) by mouth every four (4) hours Disp
#*40 Tablet Refills:*0
6. Levofloxacin 750 mg PO Q24H Duration: 5 Days
RX *Levaquin 750 mg 1 Tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
7. Nafcillin 2 g IV Q4H Duration: 14 Days
From ___
RX *nafcillin in D2.4W 2 gram/100 mL Infuse 2gm every 4hrs via
antibiotic pump every four (4) hours Disp #*60 Bag Refills:*0
8. Nicotine Patch 14 mg TD DAILY
9. traZODONE 100 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left third finger infection
Right upper/middle lobe pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with new PICC.
COMPARISONS: None.
Portable upright frontal radiograph of the chest was obtained. New right PICC
terminates in the mid SVC. Right upper lung opacity with air bronchograms and
second right midlung opacity are concerning for multifocal pneumonia.
Cardiomediastinal contours are unremarkable. No pleural effusion or
pneumothorax.
IMPRESSION:
1. Satisfactory position of right PICC
2. Multifocal right sided pneumonia. Consider 4 week radiograph to document
resolution.
Preliminary Findings were discussed with ___ by Dr. ___ at
13:25 on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HAND INFECTION
Diagnosed with TENOSYNOV HAND/WRIST NEC
temperature: 98.8
heartrate: 93.0
resprate: 16.0
o2sat: 96.0
sbp: 153.0
dbp: 92.0
level of pain: 8
level of acuity: 3.0 | The patient was initially evaluated at ___ where
blood cx were obtained and he was given IV Unasyn. An xray of
the hand was negative for foreign
bodies and the pt was transferred to ___ for further
evaluation. The patient was admitted to the plastic surgery
service on ___ with a diagnosis of Suppurative tenosynovitis
of flexor sheath, left long finger. Patient was taken to the
operating room and underwent Incision and drainage, flexor
sheath, left long
finger, where immediate expression of pus was observed. The area
was irrigated and a second incision was made at the volar
surface. Patient tolerated the procedure without difficulty and
was transferred to the PACU, then the floor in stable condition.
Please see operative report for full details. Pt was
subsequently put on Vancomycin and Unasyn. Cultures are growing
mixed flora but predominantly with S. aureus. A blood cx from
the OSH is noted to be positive for a Streptococcus spp per
report.
Infectious disease was consulted to assist in determining the
antibiotic regimen necessary and appropriate to treat his
infection. A TTE was also done to r/o endocarditis and was
found to be negative. They recommended treatment for the
flexor tenosynovitis, bacteremia as well as a newly diagnosed
RUL pneumonia. He was sent home on a 2 week regimen of
nafcillin as well as a 5 day course of levaqin to treat the
pneumonia.
Neuro: The patient received po dilaudid with good effect and
adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started on
a bowel regimen to encourage bowel movement. Intake and output
were closely monitored.
ID: The patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on ___, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. All questions were answered, and patient has
appropriate follow-up care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
codeine
Attending: ___
Chief Complaint:
Hemorrhagic conversion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo right-handed man with PMH significant
for
atrial fibrillation, pancreatic cancer (stage IV with known
hepatic metastases) and a left sided stroke in ___ (with
fluent aphasia) who presents now as a transfer for incidental
finding of a very small amount of hemorrhagic conversion of his
prior stroke. The patient was DCed from the stroke service to
rehab (___) on therapeutic lovenox for his afib and cancer
related hypercoagulable state. Mr ___ only recently returned
home from rehab and has been living with his sister who is very
involved in his care. She reported to me (via phone) that the
patient has been getting very upset and frustrated with her. He
does not want her to prepare any of his medications (of which
there are ~25) without him. He becomes somewhat paranoid that
some of the pills will kill him. He will refuse to eat at times
as well.
On the day of presentation he told his niece that he wanted to
kill himself. This promoted a call to his PCP to whom he said
"I'm done with it". The patient was then section 12ed and taken
to the ED at ___. For very unclear reasons that ED ordered
a
NCHCT which showed the very small amount of hemorrhagic
conversion of his prior ischemic stroke. The patient was then
sent to ___ for further eval. At no point was the patient
experiencing any worsening of his symptoms. His language has, if
anything, been improving.
On neuro ROS: the pt denies headache, loss of vision, blurred
vision, diplopia, oscilopsia, dysarthria, dysphagia, drop
attacks, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties comprehending speech. Denies
focal weakness, numbness, paresthesias. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general ROS: the pt denies recent fever or chills. No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
- pancreatic cancer with known liver mets
- Afib
- HTN
- HLD
- prior MI s/p catheterization
- asthma, COPD
- DM
- depression
Social History:
___
Family History:
- unable to be obtained
Physical Exam:
ADMISSION EXAM:
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress
HEENT: Sclera are non-injected. Mucous membranes are moist.
CV: Heart rate is irregular
Lungs: Breathing comfortably on RA
Abdomen: soft but tender
Extremities: No evidence of deformities. No contractures.
Skin: No visible rashes. Warm and well perfused.
Psych: patient is able to express frustration with his medically
complex situation. He denies current active SI.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place ("BI") and
time
___"). Comprehension seem intact, patient is able to
follow multistep commands which cross the midline. He responds
correctly to simple Yes/No questions (are the lights on in this
room) and points to objects in the room correctly by command.
His
speech is fluent with frequent paraphasic errors (neologisms,
phonemic and semantic error) He is able to repeat words but not
phrases, not phonemically complex words and not grammatically
complex short phrases. He is able read with frequent phonemic
errors. He can name most high and low frequency objects by
spelling the word aloud and then saying it (he does still make
many errors). Normal prosody. Speech was not dysarthric. No
neglect, left/right confusion or finger agnosia.
Cranial Nerves:
I: not tested
II: visual fields full to confrontation
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia.
V: Symmetric perception of LT in V1-3
VII: R NLFF but symmetric with activation; symmetric speed and
excursion with smile.
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. No pronator drift
or rebound
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes up on the left down on the right
Sensory: normal and symmetric perception of pinprick, light
touch, vibration and temperature. Proprioception is intact.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM were symmetric with regard to cadence and
speed, no dysdiadochokinesia noted.
DISCHARGE EXAM:
Unchanged from admission
Pertinent Results:
___ 10:48PM ___ PTT-47.1* ___
___ 10:48PM WBC-8.4 RBC-3.42* HGB-11.2* HCT-34.0* MCV-99*
MCH-32.7* MCHC-32.9 RDW-15.0 RDWSD-53.1*
___ 10:48PM PLT COUNT-172
___ 10:48PM NEUTS-79.8* LYMPHS-11.4* MONOS-5.9 EOS-2.0
BASOS-0.4 IM ___ AbsNeut-6.74* AbsLymp-0.96* AbsMono-0.50
AbsEos-0.17 AbsBaso-0.03
___ 10:48PM GLUCOSE-117* UREA N-36* CREAT-1.5* SODIUM-144
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-17
___ 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:20AM CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-1.7
___ ___:
Re-demonstrated is a subacute infarct in the left posterior
temporal lobe with known intraparenchymal hemorrhage and a small
amount of subarachnoid
hemorrhage in the region, with mild extension into the left
tentorium (image 11, series 3). There is no evidence of
intraventricular hemorrhage. There is no midline shift or mass
effect. No fractures are identified.
The ventricles and sulci are normal in size and configuration.
There is some mucosal thickening in the left ethmoid sinus. The
other
visualized portions of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of
the orbits are
unremarkable.
IMPRESSION:
1. Redemonstrated infarct in the left posterior temporal lobe,
with known
intraparenchymal hemorrhage, and small amount of regional
subarachnoid
hemorrhage and left tentorial subdural blood. There is no
midline shift or mass effect.
2. No fractures are identified.
NCHCT ___:
The study is slightly limited by motion artifacts.
Late subacute infarction involving the left parietal and
posterior temporal lobes is again seen. Small amount of
gyriform hyperdensity within the infarcted territory, which may
represent a combination of hemorrhage and pseudolaminar
necrosis, is stable. Thin adjacent subdural hematoma, which
extends along the left posterior falx and along the left
tentorium, is also stable. No new hemorrhage is seen. There is
no significant mass effect. The ventricles and the sulci
uninvolved by infarct are age-appropriate in size.
There is no evidence for a fracture. The imaged paranasal
sinuses and mastoid air cells are grossly well-aerated, allowing
for motion artifact.
IMPRESSION:
Stable appearance of late subacute infarction involving the left
parietal and posterior temporal lobes compared to 1 day earlier,
with small amount of gyriform hyperdensity, compatible with a
combination of hemorrhage in
pseudolaminar necrosis. Thin adjacent subdural hematoma, which
extends along the left posterior falx and left tentorium, is
also stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 140 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
2. Lantus 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Levothyroxine Sodium 25 mcg PO DAILY
4. GlyBURIDE 10 mg PO BID
5. Allopurinol ___ mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Paroxetine 20 mg PO DAILY
8. Prochlorperazine 10 mg PO DAILY
9. Metoprolol Tartrate 100 mg PO QAM
10. Metoprolol Tartrate 150 mg PO QPM
11. Pantoprazole 40 mg PO Q24H
12. Gabapentin 300 mg PO QAM
13. Gabapentin 300 mg PO QPM
14. Gabapentin 600 mg PO QHS
15. Potassium Chloride 10 mEq PO BID
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Indomethacin 75 mg PO BID
18. BuPROPion (Sustained Release) 150 mg PO BID
19. Furosemide 40 mg PO BID:PRN fluid retention
20. LaMOTrigine 200 mg PO QHS
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. BuPROPion (Sustained Release) 150 mg PO BID
3. Lantus 15 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. LaMOTrigine 200 mg PO QHS
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Paroxetine 20 mg PO DAILY
9. Furosemide 40 mg PO BID:PRN fluid retention
10. Gabapentin 300 mg PO QAM
11. Gabapentin 300 mg PO QPM
12. Gabapentin 600 mg PO QHS
13. GlyBURIDE 10 mg PO BID
14. Indomethacin 75 mg PO BID
15. Metoprolol Tartrate 100 mg PO QAM
16. Metoprolol Tartrate 150 mg PO QPM
17. Potassium Chloride 10 mEq PO BID
Hold for K >
18. Prochlorperazine 10 mg PO DAILY
19. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Intraparenchymal and subarachnoid hemorrhage
Left MCA stroke
Secondary diagnosis:
Acute kidney injury
Depression
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with bleed into bed of prior stroke. check for
stability. thank you. // Please perform between ___ if possible.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.2 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Comparison is made with prior CT head from ___ and MRI
from ___.
FINDINGS:
Re-demonstrated is a subacute infarct in the left posterior temporal lobe with
known intraparenchymal hemorrhage and a small amount of subarachnoid
hemorrhage in the region, with mild extension into the left tentorium (image
11, series 3). There is no evidence of intraventricular hemorrhage. There is
no midline shift or mass effect. No fractures are identified.
The ventricles and sulci are normal in size and configuration.
There is some mucosal thickening in the left ethmoid sinus. The other
visualized portions of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Redemonstrated infarct in the left posterior temporal lobe, with known
intraparenchymal hemorrhage, and small amount of regional subarachnoid
hemorrhage and left tentorial subdural blood. There is no midline shift or
mass effect.
2. No fractures are identified.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST.
INDICATION: ___ man with metastatic pancreatic cancer on palliative
treatment, evaluate for interval changes.
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase. IV
Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: This study involved 8 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
5) Stationary Acquisition 10.0 s, 0.5 cm; CTDIvol = 48.1 mGy (Body) DLP =
24.1 mGy-cm.
6) Spiral Acquisition 6.9 s, 75.4 cm; CTDIvol = 16.6 mGy (Body) DLP =
1,252.0 mGy-cm.
7) Spiral Acquisition 2.8 s, 31.0 cm; CTDIvol = 16.6 mGy (Body) DLP = 512.9
mGy-cm.
8) Spiral Acquisition 1.2 s, 13.0 cm; CTDIvol = 15.4 mGy (Body) DLP = 199.2
mGy-cm.
Total DLP (Body) = 1,991 mGy-cm.
COMPARISON: Comparison is made to CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Please see separate dictation for details on same-day
intrathoracic findings.
ABDOMEN:
HEPATOBILIARY: Since prior, there has been interval enlargement of a segment
VIII hypodense lesion which now measures approximately 32 x 23 mm (series 2,
image 55) previously 21 x 16 mm. Other hepatic lesions have not significantly
changed in size including the second largest 7 mm hypodense lesion in hepatic
segment VII. The gallbladder is unremarkable. There is no intrahepatic
biliary duct dilation.
PANCREAS: The pancreatic tail and body are atrophic with dilation of the
pancreatic duct, unchanged from prior. Again seen, is abrupt transition from
dilated to decompressed duct at the level of the pancreatic neck with a 14 x
14 mm hypodense mass in this region (series 2, image 64) (previously 11 x 13
mm).
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys enhance and excrete contrast symmetrically. A
subcentimeter renal hypodensity in the right upper pole is too small to
characterize but statistically likely represents a simple cyst and is
unchanged from prior. There is no hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: The abdominal aorta is mildly ectatic below the level of the renal
arteries without aneurysmal dilation. There is moderate atherosclerotic
calcification. The celiac axis, SMA, and ___ are patent. The portal vein,
splenic vein, and SMA are also patent.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Mild compression deformity of the T12 vertebral body is
unchanged. Mild retrolisthesis of L4/S1 is also unchanged.
IMPRESSION:
1. Interval enlargement of the segment VIII hepatic metastatic lesion. The
remaining liver lesions have not significantly changed from ___. Mild interval increase in a hypodense mass in the pancreatic body (now
measuring 14 x 14 mm) with upstream pancreatic duct dilation and atrophy of
the pancreatic tail.
3. Please see separate dictations for details on intrathoracic findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ yo right-handed man with PMH significant for atrial
fibrillation on lovenox, pancreatic cancer (stage IV with known hepatic
metastases), and a left sided stroke in ___ (with fluent aphasia), who
presented as a transfer for incidental finding of a very small amount of
hemorrhagic conversion of his prior stroke. Now s/p re-initation of lovenox.
AV for change in size of parenchymal and subarachnoid hemorrhage.
TECHNIQUE: Noncontrast head CTwith sagittal and coronal reformatted images..
DLP 803 mGy cm.
COMPARISON: ___ noncontrast head CT. ___ brain MRI. ___ the head and neck CTA.
FINDINGS:
The study is slightly limited by motion artifacts.
Late subacute infarction involving the left parietal and posterior temporal
lobes is again seen. Small amount of gyriform hyperdensity within the
infarcted territory, which may represent a combination of hemorrhage and
pseudolaminar necrosis, is stable. Thin adjacent subdural hematoma, which
extends along the left posterior falx and along the left tentorium, is also
stable. No new hemorrhage is seen. There is no significant mass effect. The
ventricles and the sulci uninvolved by infarct are age-appropriate in size.
There is no evidence for a fracture. The imaged paranasal sinuses and mastoid
air cells are grossly well-aerated, allowing for motion artifact.
IMPRESSION:
Stable appearance of late subacute infarction involving the left parietal and
posterior temporal lobes compared to 1 day earlier, with small amount of
gyriform hyperdensity, compatible with a combination of hemorrhage in
pseudolaminar necrosis. Thin adjacent subdural hematoma, which extends along
the left posterior falx and left tentorium, is also stable.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man with metastatic pancreatic cancer on treatment
with palliative intent.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and axial maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: This study involved 8 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
5) Stationary Acquisition 10.0 s, 0.5 cm; CTDIvol = 48.1 mGy (Body) DLP =
24.1 mGy-cm.
6) Spiral Acquisition 6.9 s, 75.4 cm; CTDIvol = 16.6 mGy (Body) DLP =
1,252.0 mGy-cm.
7) Spiral Acquisition 2.8 s, 31.0 cm; CTDIvol = 16.6 mGy (Body) DLP = 512.9
mGy-cm.
8) Spiral Acquisition 1.2 s, 13.0 cm; CTDIvol = 15.4 mGy (Body) DLP = 199.2
mGy-cm.
Total DLP (Body) = 1,991 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: CT chest dated ___.
FINDINGS:
Neck/cardiomediastinal: The imaged thyroid is unremarkable. There is no
evidence of supraclavicular or axillary lymphadenopathy. A sub-carinal
necrotic lymph node measures 2.2 cm, previously 1.8 cm. The degree of hilar
lymphadenopathy has increased. As an example, a left inferior hilar lymph
node now measures 1.1 cm (301:132), previously measuring 0.7 cm. A right
hilar lymph node measures 1.2 cm (301:113), previously measuring 1.0 cm.
Mediastinal lymphadenopathy has overall increased. A right ___
lymph node measures 1.5 cm, previously measuring 0.9 cm. The heart is normal
in size. There is a trace pericardial effusion. The aorta and main pulmonary
artery are top-normal.
Lungs/airways: The tracheobronchial tree is patent to the subsegmental level.
There has been interval development of a small right pleural effusion with the
suggestion of pleural nodularity (301:137). Bilateral upper lobe predominant
centrilobular ground-glass and peribronchial opacities are new. Areas of
___ are seen in the right lower lobe. There appears to be increased
interstitial markings and thickening of the lower lobe interlobular septa.
Abdomen: Please refer to abdomen/pelvic CT for evaluation of infra
diaphragmatic structures.
Bones and soft tissues: There are no suspicious bony or soft tissue lesions.
IMPRESSION:
1. Short term interval development of predominately upper lobe peribronchial
and centrilobular opacities suggests an infectious etiology, A rapidly
developing malignancy cannot be excluded, but substantially less likely.
2. Findings compatible with progression of disease, such as slight interval
increase in lymphadenopathy as described. See same day CT abdomen/pelvis for
details regarding infra-diaphragmatic structures.
3. Interstitial finding compatible with volume overload.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ service) on the telephone on ___ at 5:08 ___, 5 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, INTRACRANIAL HEMORR NOS
temperature: 98.6
heartrate: 80.0
resprate: 16.0
o2sat: 96.0
sbp: 127.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the neurology service on ___ as
a transfer from an outside hospital ED for intraparenchymal
hemorrhage as noted in the HPI. Lovenox was held initially.
#NEUROLOGY
Neurologically, his exam was noted to be unchanged from prior
admission and remained stable. NCHCT was repeated and showed no
changes, with known small SAH with small SDH extension. Given
that hemorrhage was unchanged from prior, and he is at high risk
for stroke ___ afib and/or hypercoagulability due to pancreatic
cancer, lovenox was restarted. Repeat NCHCT 1 day later showed
no changes in the size of hemorrhage. Upon speaking with the
family, there had been plan of switching from lovenox to
apixaban as outpatient, given high cost of lovenox. We discussed
that there is no evidence for apixaban to treat
hypercoagulability from pancreatic cancer, but given likely poor
compliance with lovenox (patient resistant to two injections per
day) in addition to high cost, after conversation with PCP and
cardiologist, Mr. ___ was switched to apixaban 5mg BID (no
need for renal dosing given normal renal function on discharge
see below but surveillance of renal function and adjustment
accordingly is necessary).
#RENAL
His creatinine was elevated on admission to 1.6 (confirmed poor
PO intake in ___ days prior to admission), likely pre-renal and
downtrended to 1.1 upon discharge with IVF and good PO intake.
#PSYCH/SOCIAL
As in HPI, sister had sent patient in for question of suicidal
ideation. Patient was in good spirits here and denied suicidal
ideation. He was seen by social work given concern for poor
situation at home. Patient expressed that he felt safe going
home with his sister, and his sister agreed to take him home. He
was offered an alternative (rehab) but he declined.
#HEME/ONC
Patient was scheduled for a CT torso with contrast as
outpatient, which was done as inpatient on the day of discharge
per family request. Results to be followed up upon by Dr.
___ wanted these images, final read pending at time
of discharge.
#TRANSITIONAL ISSUES
[ ] CT torso results |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Hydralazine
Attending: ___.
Chief Complaint:
Pneumoperitoneum
Major Surgical or Invasive Procedure:
none. Observation only
History of Present Illness:
___ M with a recent diagnosis of small vessel vasculitis on 60 mg
of prednisone daily, transferred from ___ for
evaluation of incidental pneumoperitoneum on CXR. 2d ago,
patient's ICD detected rapid runs of SVT. Since he had a routine
follow up appointment in the ___ clinic at ___
today, his cardiologist ordered EKG and CXR for further
evaluation. After he went home, he received a call that his CXR
showed new pneumoperitoneum. He then presented to the ED at
___, where he had a CT scan that showed
pneumoperitoneum and R colon pneumatosis.
Of note, he reports ~ 25 lb weight loss since his diagnosis of
vasculitis several months ago. He denies nausea, vomiting,
diarrhea, fevers, chills, blood in stools. He is having good
oral intake and normal bowel movements. He has had a dull
abdominal pain for the last 2 days which he did not think was
anything significant. He thought it was reflux and he took some
Tums. He denies recent use of NSAIDs, and history of peptic or
duodenal ulcers. He did not have recent surgeries. He had a
normal colonoscopy in ___.
Past Medical History:
COPD
Hypertension
Diabetes mellitus, type II
Atrial fibrillation
Nonischemic cardiomyopathy with an EF of 30%
___ Heart Association class II, heart failure
ICD in ___ ___
Left knee surgery for meniscal tear
Right meniscal tear
Right foot surgery for hammertoe
Left rotator cuff tear
Arthritis
Social History:
___
Family History:
No h/o autoimmune dz
Sister, deceased, lung ca (smoker)
Mother, deceased, breast ca
Physical Exam:
PE:
Vitals: ___ 154/77 17 100%RA
General: comfortable, in no acute distress
HEENT: sclera anicteric, mucus membranes moist, nares clear,
trachea at midline
CV: irregular rate and rhythm. No appreciable murmurs, rubs,
gallops
Pulm: clear to auscultation bilaterally
Abd: Soft/ND/NT. No hernias, masses or scars. No rebound, no
guarding. + bowel sounds
MSK: warm, well perfused
Rectal: brown stool in vault, no gross blood, guaiac negative
Neuro: alert, oriented to person, place, time
PE on discharge:
VS: VSS, afebrile
Gen: A&O x3, moving around comfortably, no distress
CV: irregular rate and rhythm. No appreciable murmurs, rubs,
gallops
Pulm: clear to auscultation bilaterally
Abd: Soft/ND/NT. No hernias, masses or scars. No rebound, no
guarding. + bowel sounds
MSK: warm, well perfused
Pertinent Results:
___ 06:00AM BLOOD WBC-6.1 RBC-4.48* Hgb-10.2* Hct-33.2*
MCV-74* MCH-22.9* MCHC-30.9* RDW-18.7* Plt ___
___ 05:55AM BLOOD WBC-6.4 RBC-4.39* Hgb-10.0* Hct-32.6*
MCV-74* MCH-22.9* MCHC-30.8* RDW-18.6* Plt ___
___ 06:00AM BLOOD Glucose-112* UreaN-37* Creat-1.7* Na-140
K-3.9 Cl-100 HCO3-31 AnGap-13
___ 05:55AM BLOOD Glucose-75 UreaN-45* Creat-2.0* Na-140
K-3.3 Cl-98 HCO3-34* AnGap-11
___ 06:00AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.4
___ 05:55AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.3
Imaging:
___ CXR IMPRESSION: New moderate pneumoperitoneum.
___ OSH CT Torso (___) Wet red: Pneumoperitoneum with R
colon pneumatosis and portal venous gas
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO 1X/WEEK (___)
2. Amiodarone 400 mg PO BID
3. Bumetanide 2 mg PO BID
4. Carvedilol 12.5 mg PO BID
5. CycloSPORINE (Sandimmune) 75 mg PO Q24H
6. Digoxin 0.125 mg PO DAILY
7. Lantus (insulin glargine) 30 u subcutaneous qpm
8. isosorbide mononitrate 30 mg oral daily
9. Metolazone 2.5 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
11. Potassium Chloride 20 mEq PO DAILY
12. PredniSONE 60 mg PO DAILY
13. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
14. Valsartan 40 mg PO DAILY
15. Warfarin 2.5 mg PO 2X/WEEK (___)
16. Warfarin 1.25 mg PO 5X/WEEK (___)
Discharge Medications:
1. Amiodarone 400 mg PO BID
Amiodarone Taper:
400mg 2x/day for 7 days
300mg 2x/day for 2 weeks
then 200mg 2x/day
2. Carvedilol 12.5 mg PO BID
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
4. PredniSONE 60 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
7. Alendronate Sodium 70 mg PO 1X/WEEK (___)
8. Bumetanide 2 mg PO BID
9. CycloSPORINE (Sandimmune) 75 mg PO Q24H
10. Lantus (insulin glargine) 30 u SUBCUTANEOUS QPM
11. Metolazone 2.5 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. Valsartan 40 mg PO DAILY
14. Warfarin 1.25 mg PO DAILY16
15. Digoxin 0.125 mg PO EVERY OTHER DAY
Take every other day
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumoperitoneum - unknown source
Discharge Condition:
Mental status: clear and coherent
Ambulation: independent
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with runs of SVT rapid afib. // Pt starting
amiodarone Pt starting amiodarone
COMPARISON: Chest radiographs since ___ most recently ___.
Impression
IMPRESSION:
New moderate pneumoperitoneum. Unless the patient has had an invasive
procedure introducing air in to the abdomen, this is an indication of an
intestinal perforation.
Moderate cardiomegaly, unchanged since ___. Lungs well expanded and clear.
There is no pleural effusion. Trans subclavian right ventricular pacer
defibrillator lead unchanged in position since at least ___,
continuous from the left pectoral PET generator.
NOTIFICATION: Dr. ___ reported the findings to ___ by
telephone on ___ at 3:25 ___, 0.5 minutes after discovery of the
findings. Dr. ___ reported the findings to Dr ___ by telephone on
___ at 3:27 ___, 3 minutes after discovery of the findings.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: PERFORATED BOWEL, Transfer
Diagnosed with PERITONEAL DISORDER NEC
temperature: 98.0
heartrate: 65.0
resprate: 17.0
o2sat: 100.0
sbp: 154.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ M on 60 mg of prednisone daily presents with incidental free
air seen on CXR. Subsequent CT scan w/ pneumoperitoneum, R colon
pneumatosis. Patient is completely asymptomatic, hemodynamically
stable, and non-tender on exam. The patient was admitted to the
Acute Care Surgery service for observation. He was started on IV
antibiotics, kept nothing by mouth, given IV fluids, and
monitored closely with serial abdominal exams.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability. The patient voided without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and had no pain.
The patient was discharged home without services. The patient
was discharged with a prescription to complete a 2-week course
of antibiotics for a suspected GI source of the
pneumoperitoneum. The patient had follow-up scheduled with his
cardiologist, rheumatologiost, and in the ___ clinic. He was
instructed on danger signs to watch for when home. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Aspirin / AmBisome
Attending: ___.
Chief Complaint:
headache, fevers, chills, neck stiffness, myalgias
Major Surgical or Invasive Procedure:
lumbar puncture ___
History of Present Illness:
Ms. ___ is a ___ with a history of HIV on HAART (last CD4
___ ___ that has been complicated by previous
noncompliacne, PCP pneumonia, cryptococcal pneumonia, possible
recurrent aseptic meningitis- also with ___
malformation abd migraine headaches who presents to the ED with
headache, fevers, chills and malaiase.
On arrival to the ED, her initial vitals were T100.0 98 108/59
16 98%RA. A lumbar puncture was bland with a single WBC and RBC
on tube 4. and a normal glucose and protein. CT head revealed no
intracranial bleeds or masses (within the confines of a
noncontrast study), and CXR unremarkable. Due to a history of
cryptococcal meningitis and possible aseptic meningitis, she was
admitted for full workup.
On arrival to the medicine floor, the patient feels much better.
She describes a progressive 1 week syndrome that began with a
dry cough, throat irritation, and general malaise. Three days
ago, she developed chest tightness and shortness of breath
reminiscent of her typical asthma symptoms though they did not
respond to inhalers. Two days ago she developed overwhelming
myalgias, arthralgias, and a headache, which was severe. The
headache was ___, assumed a circular distribution around the
entirety of the head with the epicenter located at the right
temple- the area where her previous VP shunt exited. There was
tenderness at the base of the skull with tightness of the neck
radiating down the paraspinal musculature. She complaines of
"spots" in her vision, but no lack of acuity. There is photo and
phonophobia. The headache is similar to migrains which she gets
on a weekly basis and which respond to exedrine.
She measuired temps of 101.2 on ___, and had further fevers
and chills yesteday. She complains of some nausea and a few
bouts of vomiting three days ago. She complains of 5 days of
watery nonbloody diarrhea occurring ___ times a day. Coughing,
chest tightness and phlegm production continue, along with body
aches. Her mom also had cold-like symptoms this week, and a son
had strep throat two months ago. She received a flu shot one
month ago.
She thinks that initially her symptoms were similar to previous
episodes of aseptic meningitis, but they resolved much quicker
than usual with conservative treatment. She has not tried any
OTC meds at this point. She denies recent confusion, odd
behavior, speech difficulties, seizures, incontinence.
She has had a number of presentations of headache and neck
stiffness previously. She was admitted ___ with HA/neck
stiffness however two LPs were quite bland and infectious workup
including toxo, crypto, HSV, VZV were negative. Neuro felt it
consistent with migraines and she was treated successfully with
muscle relaxants. In ___ she was admitted with headache,
vertigo, and neck stiffness and again underwent an infectious
workup with bland LP, negative HSV, and a normal MRI of the
brain. She improved with muscle relaxants during this admission
as well. She was admitted ___ and ___ with a headache, and
had normal LPs each time- she was diagnosed with migraines.
___ she presented with head, fever, stiff neck and was
actuially diagnosed with cryptococcal meningitis requiring VP
shunt for elevated intracranial pressure. She had
cryptococceemia in ___ with normal LP. She was diagnosed with
aseptic meningitis in ___ with a CSF WBC of 45 without
positive cultures. Her first admit was ___ with HA/neck
stiffness and URI symptoms with a negaitve LP.
Past Medical History:
1) HIV/AIDS- diagnosed in ___ when she presented with
streptococcal pharyngitis and an aseptic meningitis. She has
intermittently been engaged in care. She initated HAART in ___
with Truvada and Atazanvir. She notes intermittent compliance
with this regimen since then. last CD4 count ___ 826
2) Disseminated crypto and meningitis ___, recurrences of
cryptococcemia in ___ and ___ VP shunt; s/p shunt
removal
3) Hx of PJ pneumonia ___ Recurrent STDS (Chlamydia, gonorrhea, trich, HSV)
5) recurrent sinusitis
6) 2x aseptic meningitis
7) migraines
8) asthma
9) depression
10) hx zoster
11) M. ___ isolated from sputum in ___ Chiari malformation
13) Tobacco use
14) Dental work- teeth removed ___.
15) LEEP; laser ablation of condyloma of cervix, vagina and
vulva; and laser ablation of vulvar intraepithelial neoplasia
(___)
Social History:
___
Family History:
Mother and father both with migraines.
Physical Exam:
Admission exam:
VS - Temp99.1 BP106/62 , HR65 , RR18 , O2-sat 99% RA
GENERAL: well appearing, mildly fatigued
HEENT: MMM, oropharynx is clear, normal EOM, PERRLA. fundoscopic
exam limited due to pupillary constriction and color but could
not appreciate papilledema.
NECK: no adenopathy, normal ROM
PULM: CTAB without RRW
HEAERT: RRR normal S1 S2 no MRG
ABD: soft without tenderness to palpation
SKIN: no signs of infection
BACK: tenderness to palp of trapezius bilaterally and all
posterior paraspinal musculature.
NEURO: cranial nerves all intact bilaterally, strength ___
throughout, normal sensory exam to soft touch. full ROM of the
neck- can touch chin to chest. Negative kernig and brudzinski
tests bilaterally. finger to nose, RAM, HTS all in tact.
MSE: fully oriented and appropriate with all questioning
Discharge Exam:
afebrile, decreased neck stiffness and back pain, otherwise
unchanged
Pertinent Results:
Admission Labs:
___ 02:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:10PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* POLYS-0
___ ___ 12:09PM CEREBROSPINAL FLUID (CSF) PROTEIN-29
GLUCOSE-62
___ 09:50AM GLUCOSE-93 UREA N-12 CREAT-0.6 SODIUM-136
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-20* ANION GAP-12
___ 09:50AM WBC-4.4 RBC-3.83* HGB-12.0 HCT-36.6 MCV-96
MCH-31.4 MCHC-32.8 RDW-12.8
___ 09:50AM NEUTS-47* BANDS-1 ___ MONOS-9 EOS-2
BASOS-0 ___ MYELOS-0
___ 09:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 09:50AM PLT SMR-NORMAL PLT COUNT-207
Discharge Labs:
___ 06:15AM BLOOD WBC-3.0* RBC-3.69* Hgb-11.5* Hct-35.7*
MCV-97 MCH-31.1 MCHC-32.2 RDW-12.7 Plt ___
___ 06:15AM BLOOD Neuts-22* Bands-0 Lymphs-61* Monos-15*
Eos-1 Baso-0 Atyps-1* ___ Myelos-0
___ 06:15AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-139
K-4.2 Cl-107 HCO3-23 AnGap-13
___ 06:15AM BLOOD ALT-17 AST-22 AlkPhos-67 TotBili-0.1
___ 06:15AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.8
Microbiology:
___ 12:09 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary):
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
___ 9:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:14 am Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
Imaging:
NONCONTRAST HEAD CT ___: No acute intracranial abnormality
CXR ___: No acute intrathoracic abnormality
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Darunavir 800 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Fluconazole 200 mg PO Q24H
4. Raltegravir 400 mg PO BID
5. RiTONAvir 100 mg PO DAILY
6. albuterol inhaler
Discharge Medications:
1. Darunavir 800 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Fluconazole 200 mg PO Q24H
4. Raltegravir 400 mg PO BID
5. RiTONAvir 100 mg PO DAILY
6. Cyclobenzaprine 10 mg PO TID:PRN neck pain or stiffness
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth three times a day
Disp #*10 Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/tightness
RX *albuterol sulfate 90 mcg ___ puffs inhaled every ___ Disp
#*1 Inhaler Refills:*1
8. Medical equipment
please provide nebulizer machine
diagnosis: Asthma 493.9
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/tightness
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb(s) every ___
hours Disp #*1 Box Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Acute viral infection
migraine headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Headache, cough and fever.
COMPARISON: Chest radiograph ___.
FINDINGS: PA and lateral views of the chest were obtained. The lungs are
clear bilaterally with no evidence of focal consolidation or pulmonary edema.
There is no pleural effusion or pneumothorax. The cardiomediastinal
silhouette is normal. There are no bony abnormalities. There is no free air
below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
Radiology Report
INDICATION: Headache, cough, and fever.
COMPARISON: CT head ___.
TECHNIQUE: MDCT axial images were acquired through the brain without the
administration of IV contrast. Sagittal, coronal and thin section bone
algorithm reformats were obtained.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema,
masses or mass effect. Ventricles and sulci are normal in size and
configuration. Basal cisterns are patent. Gray-white differentiation is
preserved.
Right frontal burr hole again noted. The visualized portions of the paranasal
sinuses, mastoid air cells and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION: No mass or acute intracranial process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: NECK STIFFNESS
Diagnosed with TORTICOLLIS NOS
temperature: 100.0
heartrate: 98.0
resprate: 16.0
o2sat: 98.0
sbp: 108.0
dbp: 59.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ with a history of HIV/AIDS and previous
cryptococcal meningitis here with HA, fevrs, chills, myalgias
and arthralgias that was probably due to acute viral syndrome
with superimposed migraine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
___ PMHx significant for severe vascular diseae & hypertension
presents with 4 days of ___ and epigastric pain, inability to
tolerate PO.
He states that the pain is constant, hasn't changed since the
onset. He had had multiple vascular interventions in the abdomen
and bilateral extremities, but no previous open abdominal
surgeries.
He denied fever, hematochezia, dysuria, hematuria. He has
vomited all the food he has attempted to eat. No history of
diverticulitis. He has never had colonoscopy.
In the ED, initial vitals were: pain ___, T 99.2, HR 75, BP
152/75, R 20, SpO2 96%/RA
And patient was given
___ 21:14 IVF 1000 mL NS 1000 mL ___
___ 00:01 IV Furosemide 20 mg ___
___ 07:54 PO/NG Amlodipine 10 mg ___
___ 07:54 PO/NG Aspirin 325 mg ___
___ 07:54 PO/NG Lisinopril 20 mg ___
___ 07:54 PO Omeprazole 20 mg ___
___ 08:05 PO Potassium Chloride 40 mEq ___
___ 08:05 IV Magnesium Sulfate 2 gm ___
___ 08:05 IV Furosemide 20 mg ___
___ 08:07 IH Tiotropium Bromide 1 CAP ___
- Labs were notable for: leukopenia (3.3), hyponatremia (128),
pro-BNP 7781, UA with moderate blood, >600 proteinuria, 70
glucose, lactate 1.5, trop-T 0.01
- Patient was given: 1L NS then 20 mg IV furosemide x 2
- CT Abd/Pelvis was obtained, showing mild cardiomegaly with
small bilateral pleural effusions. Lower lung GGOs could
represent atypical edema, but difficult to exclude early
pneumonia in LLL. Extensive vascular disease with aortiiliac
stent in place. No findings to account for ___ abdominal pain.
- CXR showing pulmonary vascular congestion & mild to moderate
pulmonary edema with a small rigth pleural effusion; no free air
below the diaphragm.
- EKG showed NSR, with IVCD and TW flattening/inversions in
lateral precordial leads
On the floor,
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
======================
PAST MEDICAL HISTORY
======================
HTN
DMII
PAD/claudication
ED
GERD
.
======================
VASCULAR HISTORY
======================
-___: Bilateral common iliac artery kissing stent
placement, Bilateral external iliac artery stent placement
-___: Bilateral simultaneous angioplasty of common iliac
artery stents
-___: Placement of a 7 mm x 59 mm iCAST stent into the
left
common iliac artery.Placement of kissing stents into the
bilateral common iliac artery origins measuring 7 mm x 37 mm,
Express LD stents.
Social History:
___
Family History:
coronary artery disease, MI, diabetes, thromboembolism
Physical Exam:
ADMISSION
VS: 98.7 130/76 65 16 99RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE
Weight: 75.4 kg (standing)
VS: T 98.1F BP 113/59 P 61 RR 18 O2 99% RA
General: NAD, comfortable, pleasant
HEENT: PERRL, EOMI
Neck: supple, no JVD
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Abd: Soft, non-tender, non-distended.
Ext: Warm, and well-perfused. R radial pulse 2+.
Neuro: A&Ox3; MAEx4
Pertinent Results:
ADMISSION
___ 05:03PM BLOOD WBC-3.3*# RBC-5.12# Hgb-15.7# Hct-46.0#
MCV-90 MCH-30.7 MCHC-34.1 RDW-14.7 RDWSD-48.0* Plt ___
___ 05:03PM BLOOD Glucose-151* UreaN-19 Creat-1.2 Na-128*
K-4.3 Cl-94* HCO3-22 AnGap-16
___ 05:00AM BLOOD ALT-36 AST-27 AlkPhos-93 TotBili-0.4
___ 06:00AM BLOOD Calcium-8.3* Phos-4.1 Mg-1.8
___ 05:18PM BLOOD Lactate-1.5
DISCHARGE
___ 04:52AM BLOOD WBC-5.6 RBC-4.67 Hgb-14.0 Hct-42.8 MCV-92
MCH-30.0 MCHC-32.7 RDW-14.1 RDWSD-47.4* Plt ___
___ 04:52AM BLOOD Glucose-136* UreaN-17 Creat-0.8 Na-133
K-4.7 Cl-101 HCO3-23 AnGap-14
___ 04:52AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
CXR ___
Pulmonary vascular congestion and mild to moderate pulmonary
edema with small
right pleural effusion. No signs of free air below the right
hemidiaphragm.
CT ABD/PELVIS ___
1. Mild cardiomegaly with small bilateral pleural effusions.
Lower lung
ground-glass opacities may represent atypical edema, difficult
to exclude an
early pneumonia in the left lower lobe.
2. Extensive vascular disease with aortoiliac stent in place,
appearing
patent.
3. No findings the left lower quadrant to account for pain.
TRANSTHORACIC ECHOCARDIOGRAM (___):
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
moderate global left ventricular hypokinesis (LVEF = ___ %).
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal with depressed free wall contractility. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
CARDIAC CATHETERIZATION (___):
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is without obstructive dz.
* Left Anterior Descending
The LAD has a 70% long distal stenosis.
The ___ Diagonal is not obstructed.
* Circumflex
The Circumflex is 80% narrowed proximally.
The ___ Marginal is minimall diseased.
* Right Coronary Artery
The RCA is engaged non-selsctively and has a long proximal 80%
stenosis.
The Right PDA is not well visualized but look patent.
Impressions:
1. 3 vessel disease in a diabetic with reduced EF
2. Extreme tortuosity making selective engagement of RCA
difficult, so non selective injections obtained
___ DUP EXTEXT BIL (MAP) (___):
FINDINGS:
Right lower extremity: Both the great and small saphenous veins
are patent in the right lower extremity. The great saphenous
vein caliber ranges from 0.12-0.27 cm. The small saphenous vein
caliber ranges from 0.17-0.24 cm.
Left lower extremity: Both the great and small saphenous veins
are patent in the left lower extremity. The great saphenous
vein caliber ranges from
0.22-0.36 cm. The small saphenous vein caliber ranges from
0.18-0.31 cm.
IMPRESSION:
Patent bilateral great and small saphenous veins. For detailed
description of calibers please refer to sonographer report in
PACs.
CAROTID SERIES COMPLETE (___):
IMPRESSION:
Mild homogeneous atherosclerotic plaque in the left ICA and mild
intimal
thickening in the right ICA resulting in less than 40% stenosis
bilaterally.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN PAIN
2. Lisinopril 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Labetalol 400 mg PO BID
6. MetFORMIN (Glucophage) 850 mg PO TID
7. Docusate Sodium 100 mg PO DAILY
8. Cyclobenzaprine 5 mg PO TID
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Amlodipine 10 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CHEST PAIN
13. TraMADOL (Ultram) 50 mg PO BID:PRN PAIN
14. Clopidogrel 75 mg PO DAILY
15. Aspirin 325 mg PO DAILY
16. GlipiZIDE 10 mg PO BID
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN DYSPNEA
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN PAIN
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN DYSPNEA
3. Amlodipine 10 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at night Disp #*90
Tablet Refills:*0
5. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Gabapentin 300 mg PO TID
8. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*90 Tablet Refills:*0
9. Cyclobenzaprine 5 mg PO TID
10. Docusate Sodium 100 mg PO DAILY
11. GlipiZIDE 10 mg PO BID
12. MetFORMIN (Glucophage) 850 mg PO TID
13. TraMADOL (Ultram) 50 mg PO BID:PRN PAIN
14. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
------------------
ACUTE SYSTOLIC HEART FAILURE
CORONARY ARTERY DISEASE
VIRAL GASTROENTERITIS
SECONDARY DIAGNOSIS
--------------------
DIABETES
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with epigastric pain
COMPARISON: Prior exam from ___. Outside hospital CT exam from ___.
FINDINGS:
PA and lateral views of the chest provided. Lateral view suboptimal due to
underpenetration. There is hilar congestion with mild to moderate
interstitial pulmonary edema. A small pleural effusion on the right is noted.
No pneumothorax. Heart size is normal. Bony structures appear intact. No
free air below the right hemidiaphragm.
IMPRESSION:
Pulmonary vascular congestion and mild to moderate pulmonary edema with small
right pleural effusion. No signs of free air below the right hemidiaphragm.
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ with LLQ pain
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. Oral contrast was not administered. Coronal and
sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 621 mGy-cm.
COMPARISON: Prior CT abdomen pelvis performed at an outside hospital on ___.
FINDINGS:
LOWER CHEST: Small bilateral pleural effusions are present. There is mild
compressive lower lobe atelectasis. Areas of ground-glass and nodular opacity
in the left lower lobe may represent an atypical pneumonia versus asymmetric
pulmonary edema. Small hilar calcified lymph nodes are partially visualized.
The heart is mildly enlarged.
ABDOMEN: The liver enhances normally without focal concerning lesion. The
gallbladder appears normal. No intrahepatic or extrahepatic biliary ductal
dilation. Main portal vein is patent. The spleen is normal. Adrenal glands
are normal bilaterally. The pancreas appears normal. The kidneys enhance
symmetrically and excrete contrast promptly. There is an area of scarring
along the left midpole at the site of prior infarction. A simple appearing
left upper pole renal cyst is again noted. The stomach is decompressed. The
duodenum appears normal. Loops of small bowel demonstrate no signs of ileus
or obstruction. No mesenteric fluid or adenopathy.
The abdominal aorta contains extensive atherosclerosis as on prior with distal
aortoiliac stents again noted which remain patent. No retroperitoneal
adenopathy or hematoma.
PELVIS: The appendix is normal. The colon contains a mild fecal load and is
without wall thickening or signs of acute inflammation. No abnormality in the
left lower quadrant to account for pain. No pelvic free fluid. No pelvic
sidewall or inguinal adenopathy. The urinary bladder is decompressed. Distal
ureters opacify normally.
BONES: No worrisome lytic or blastic osseous lesion is seen.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mild cardiomegaly with small bilateral pleural effusions. Lower lung
ground-glass opacities may represent atypical edema, difficult to exclude an
early pneumonia in the left lower lobe.
2. Extensive vascular disease with aortoiliac stent in place, appearing
patent.
3. No findings the left lower quadrant to account for pain.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with 3vd undergoing w/u for CABG. Please perform
carotid ultrasound
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None available
FINDINGS:
RIGHT:
The right carotid vasculature shows mild intimal thickening.
The peak systolic velocity in the right common carotid artery is 56 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 42, 60, and 79 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 30 cm/sec.
The ICA/CCA ratio is 1.4.
The external carotid artery has peak systolic velocity of 304 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild homogeneous atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 53 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 73, 70, and 63 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 36 cm/sec.
The ICA/CCA ratio is 1.4.
The external carotid artery has peak systolic velocity of 79 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Mild homogeneous atherosclerotic plaque in the left ICA and mild intimal
thickening in the right ICA resulting in less than 40% stenosis bilaterally.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with ___ undergoing w/u for CABG. Please perform
lower extremity vein mapping pre-CABG.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
Right lower extremity: Both the great and small saphenous veins are patent in
the right lower extremity. The great saphenous vein caliber ranges from
0.12-0.27 cm. The small saphenous vein caliber ranges from 0.17-0.24 cm.
Left lower extremity: Both the great and small saphenous veins are patent in
the left lower extremity. The great saphenous vein caliber ranges from
0.22-0.36 cm. The small saphenous vein caliber ranges from 0.18-0.31 cm.
IMPRESSION:
Patent bilateral great and small saphenous veins. For detailed description of
calibers please refer to sonographer report in PACs.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by WALK IN
Chief complaint: LLQ abdominal pain
Diagnosed with Heart failure, unspecified
temperature: 99.2
heartrate: 75.0
resprate: 20.0
o2sat: 96.0
sbp: 152.0
dbp: 75.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ year old man with a PMHx significant for
severe vascular diseae & hypertension presented with 4 days of
___ and epigastric pain, inability to tolerate PO.
# Acute systolic heart failure. New diagnosis. Fluid
resuscitated in ED with 1L NS and this caused acute onset of
shortness of breath and pulmonary edema. CXR showed pulmonary
vascular congestion, and BNP obtained was 7k. Admitted to heart
failure service for new diagnosis of CHF. Echo on admission
showed EF of 30% to 35%. Initially diuresed well with boluses of
20 IV Lasix, maintained euvolemia without maintenance diuretic.
Work up revealed 3vessel coronary artery disease. Cardiac
surgery evaluated and recommended CABG. Vascular surgery
approved discontinuation of Plavix given recent stent.
# ___ ABDOMINAL PAIN: History of renal infarct that presented
similarly in ___. CT abdomen/pelvis unrevealing for etiology
of abdominal pain. Etiology thought to be likely viral
gastroenteritis. Improved considerably and was taking full POs
by the time of discharge.
# Proteinuria: patient has urine Pr/Cr ratio 5.4. Renal
consulted and recommended etiology was likely diabetic
nephropathy. Bp med changes included uptitration of ACE. No
renal biopsy required.
CHRONIC ISSUES
# DIABTES MELLITUS: Hb A1c 8.6%.
# PERIPHERAL ARTERIAL DISEASE: maintained on home dose Asa 325.
Plavix stopped ahead of CABG.
TRANSITIONAL ISSUES
-------------------
WEIGHT ON ADMISSION : 71.6 kgs
WEIGHT ON DISCHARGE: 70.9 kg
DISCHARGE CR:0.8
# 3 VESSEL CORONARY ARTERY DISEASE: Patient scheduled for
outpatient CABG on ___. Stop metformin on ___. Stop lisinopril
on ___.
# NEW DIAGNOSIS OF HEART FAILURE: Likely ischemic in nature,
full evaluation otherwise negative. Patient NOT started on
maintenance diuretic. Discharged with ACEi, carvedilol, ASA,
high dose statin
# MED CHANGES:
Aspirin decreased from 325 to 81
Lisinopril increased to 40mg daily
Clopidogrel discontinued
Hydrochlorthiazide discontinued
Labetolol discontinued
# Consider Hep A/B vaccination |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of
asthma, depression/anxiety, active tobacco smoking who presents
with acute onset chest pain with exertion.
Patient describes nearly ten minutes of left sided chest pain,
dull in quality and non-radiating while walking to work. There
was some associated shortness of breath, though he is a smoker
and also thought he was affected by the humid weather. No
nausea,
palpitations, or lightheadedness/dizziness. After the pain
resolved spontaneously, patient experienced two subsequent
short-lived episodes in quick succession. Throughout the day, he
then noticed some left hand numbness, which he attributed to
known carpal tunnel. Later on in the afternoon, patient
presented
for a previously scheduled dental procedure, which was deferred
iso hypertension (163/109). Patient was instructed to undergo
evaluation at an urgent ___, which he did. ECG showed a
new RBBB compared to ___ and so patient was loaded with aspirin
and told to present to the ___ ED.
Upon initial evaluation in the ED, patient experienced another
episode of the same chest discomfort, dull and left-sided,
self-limited and without any significant associated symptoms.
In the ED initial vitals were: 97.7 89 149/93 18 97% RA
Past Medical History:
Past Medical History:
-Depression
-Anxiety
Past Surgical History:
-Ventral hernia repair as a child
-Lithotripsy
-Oral mucosal bx
Social History:
___
Family History:
Denies history of IBD or GI cancer.
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 1125)
Temp: 98.1 (Tm 98.1), BP: 138/83 (138/83-87), HR: 77
(74-77),
RR: 18 (___), O2 sat: 97% (97-98), O2 delivery: Ra
GENERAL: Well developed, well nourished man in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
CARDIAC: Regular rate, normal rhythm. Normal S1, S2. No
murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No peripheral edema.
SKIN: No significant skin lesions or rashes.
=======================
DISCHARGE PHYSICAL EXAM
=======================
VS: 24 HR Data (last updated ___ @ 328)
Temp: 98.5 (Tm 98.5), BP: 114/78 (114-168/77-96), HR: 68
(66-78), RR: 17 (___), O2 sat: 96% (94-98), O2 delivery: ra
GENERAL: Well developed, well nourished man in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric.
CARDIAC: Regular rate, normal rhythm. Normal S1, S2. No
murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No peripheral edema.
SKIN: No significant skin lesions or rashes.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 05:45PM URINE MUCOUS-RARE*
___ 05:45PM URINE RBC-11* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:45PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:45PM ___ PTT-25.9 ___
___ 05:45PM PLT COUNT-209
___ 05:45PM NEUTS-60.7 ___ MONOS-4.9* EOS-2.3
BASOS-0.8 IM ___ AbsNeut-5.18 AbsLymp-2.64 AbsMono-0.42
AbsEos-0.20 AbsBaso-0.07
___ 05:45PM WBC-8.5 RBC-4.97 HGB-16.7 HCT-45.0 MCV-91
MCH-33.6* MCHC-37.1* RDW-12.5 RDWSD-41.1
___ 05:45PM URINE UHOLD-HOLD
___ 05:45PM URINE HOURS-RANDOM
___ 05:45PM cTropnT-<0.01
___ 05:45PM estGFR-Using this
___ 05:45PM GLUCOSE-83 UREA N-13 CREAT-0.8 SODIUM-144
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 08:45PM cTropnT-<0.01
___ 11:51PM cTropnT-<0.01
=================
PERTINENT STUDIES
=================
EKG ___: NSR (84bpm), right access deviation, wide QRS with
RBBB,
TWIs III/aVF/aVR/V1, anterolateral STDs.
Cardiac perfusion study ___:
FINDINGS:
The image quality is adequate but limited due to soft tissue
attenuation. There is motion.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a reversible, mild
reduction in photon counts involving the distal anterior wall
and
the apex.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 56% with an
EDV of 105 ml.
IMPRESSION:
1. Reversible, mild, small perfusion defect involving the LAD
territory.
2. Normal left ventricular cavity size and systolic function.
CXR ___:
IMPRESSION:
No acute intrathoracic process
==============
DISCHARGE LABS
==============
No labs on day of discharge
___ 11:50AM BLOOD WBC-6.8 RBC-4.91 Hgb-16.7 Hct-45.6 MCV-93
MCH-34.0* MCHC-36.6 RDW-12.5 RDWSD-42.5 Plt ___
___ 11:50AM BLOOD ___ PTT-37.8* ___
___ 11:50AM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-142
K-4.3 Cl-104 HCO3-25 AnGap-13
___ 11:50AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth every night Disp
#*30 Tablet Refills:*0
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth every day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with chest pain// Please eval for PNA, effusion
COMPARISON: CT of the chest from ___
FINDINGS:
AP portable upright view of the chest. Low lung volumes. Overlying EKG leads
noted. Lungs are clear. There is no focal consolidation, effusion, or
pneumothorax. No signs of congestion or edema. The cardiomediastinal
silhouette is normal. Imaged osseous structures are intact.
IMPRESSION:
No acute intrathoracic process
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 97.7
heartrate: 89.0
resprate: 18.0
o2sat: 97.0
sbp: 149.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | Patient is leaving against medical advice. Risks of leaving the
hospital prematurely, including severe disability and death,
were discussed with the patient.
Mr. ___ is a ___ year old man with history of asthma,
depression/anxiety, active tobacco smoking who presents with
acute onset chest pain with exertion.
=============
ACTIVE ISSUES
=============
# Unstable angina:
Patient presents with new onset left-sided chest pain occurring
with exertion. Presentation is concerning for evolving coronary
artery disease, unstable angina given new onset chest pain. CAD
risk factors: active tobacco smoking with longstanding history,
hypertension. ECG notable for RBBB, inferior TWIs, and
anterolateral STDs (all new since prior tracing ___. Troponins
NEG x3. Exercise stress was transitioned to pharmacologic
stress, perfusion study shows a mild perfusion defect involving
the LAD territory.
-not taking medications at home
-started on:
heparin gtt (d/c'd ___
aspirin 81 mg PO daily
atorvastatin 80 mg PO daily
metoprolol succinate XL 50 mg PO qHS
-plan was for TTE, cardiac catheterization but patient not
willing to stay over the weekend and therefore leaving AMA
# Microscopic hematuria:
Patient has a reported history of lithotripsy. Patient should
have subsequent urine studies with possible CTU/urine
cytology/cystoscopy as an outpatient given his significant
history of smoking.
# Elevated blood pressure:
Currently normotensive, though with report of elevated BP at
urgent care.
- Consider initiation of ACE-I if persistently hypertensive
===================
TRANSITIONAL ISSUES
===================
[] continue aspirin 81 mg PO daily
[] continue atorvastatin 80 mg PO qPM
[] continue metoprolol succinate XL 50 mg PO daily
[] monitor BP as an outpatient, if persistently hypertensive,
consider starting ACEi
[] consider TTE-- recommended while inpatient, however patient
left AMA before this could be done.
[] consider cardiac catheterization-- recommended while
inpatient, however patient left AMA before this could be done.
[] consider HgbA1c, lipid panel to assess for additional cardiac
risk factors
[] repeat urine studies. Consider CTU/urine cytology/cystoscopy
if persistent microhematuria given smoking history |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish derived
Attending: ___.
Chief Complaint:
abd pain, N/V
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with a PMH of chronic Hep B,
H/ pylori s/p treatment with Prevpac, laparoscopic
cholecystectomy for biliary colic in ___, who presents
with abdominal pain.
Patient reports that two days ago she was in her usual state of
health until two days ago. She ate lunch and went to her
appointment in ___ clinic. She reports that while there
she suddenly felt sweaty, followed by sudden onset of sharp,
severe abdominal pain in the epigastric area, associated with
nausea. She went to the ED, where she reports she had an
ultrasound and labs. Her symptoms resolved, and she was
discharged home. However, the following day she ate oatmeal, and
around 30 minutes later again suddenly became diaphoretic with
epigastric pain and nausea. She again presented to the ED. She
reports no fevers or chills, no rashes, no change in bowel
movements.
In the ED:
Initial vital signs were notable for: T 97.9, HR 65, BP 123/81,
RR 16, 100% RA Exam notable for: Tenderness to palpation to the
epigastric region.
Labs were notable for:
- CBC: WBC 6.6 (52%n), hgb 13.8, plt 201
- Lytes:
143 / 107 / 13 AGap=17
------------- 80
4.2 \ 19 \ 0.7
- LFTs: AST: 405 ALT: 393 AP: 176 Tbili: 1.3 Alb: 4.2
- lipase 22
- lactate 1.4
- u/a with lg leuks, trace blood, trace protein, 40 ketones,
>182
WBCs, negative nitrites, no bacteria
Upon arrival to the floor, patient reports continued abdominal
pain and nausea which comes and goes. She feels that the nausea
may have been from her morphine. Otherwise she recounts the
history as above.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- chronic hep B infection
- biliary colic s/p laparoscopyic cholecystectomy
- hypertension
- peptic ulcer disease
- liver hemangiomas
- renal cyst
- plantar fasciitis
- Alopecia areata
Social History:
___
Family History:
- Mother Living ___ BREAST CANCER
- Father ___ ___ HYPERTENSION, DIABETES TYPE II, STROKE
- Brother Living ___ HYPERTENSION
- Aunt Deceased ___ PANCREATIC CANCER
Physical Exam:
VITALS: T 97.9, HR 68, BP 109/73, RR 18, 98% RA
GENERAL: Alert and in no apparent distress, appearing in pain
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Hypoactive bowel sounds. Abdomen soft, non-distended,
moderately tender to palpation in epigastric area. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
98.2 127/___
GEN: female in NAD
HEENT: MMM, no scleral icterus
CV: RRR no m/r/g
RESP: CTAB no w.r
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: warm, no edema
NEURO: alert, appropriately, moving all extremities
PSYCH: calm, pleasant affect
Pertinent Results:
___ 07:25PM BLOOD WBC-6.6 RBC-4.53 Hgb-13.8 Hct-42.6 MCV-94
MCH-30.5 MCHC-32.4 RDW-12.8 RDWSD-44.4 Plt ___
___ 07:30AM BLOOD WBC-5.4 RBC-4.48 Hgb-13.7 Hct-42.3 MCV-94
MCH-30.6 MCHC-32.4 RDW-12.6 RDWSD-43.8 Plt ___
___ 07:25PM BLOOD Glucose-80 UreaN-13 Creat-0.7 Na-143
K-4.2 Cl-107 HCO3-19* AnGap-17
___ 07:30AM BLOOD Glucose-83 UreaN-6 Creat-0.7 Na-146 K-3.8
Cl-107 HCO3-27 AnGap-12
___ 07:25PM BLOOD ALT-393* AST-405* AlkPhos-176*
TotBili-1.3
___ 12:53PM BLOOD ALT-574* AST-425* AlkPhos-207*
TotBili-2.5*
___ 06:32AM BLOOD ALT-408* AST-174* AlkPhos-191*
TotBili-0.9
___ 07:30AM BLOOD ALT-283* AST-69* AlkPhos-174* TotBili-0.5
RUQ US ___:
1. Mild intrahepatic biliary ductal dilation in this patient
post
cholecystectomy. No definite evidence for a retained
obstructing duct stone.
2. Echogenic foci within the right kidney, similar to prior
likely
representing angiomyolipomas.
3. Hepatic hemangioma again noted.
RUQ U/s ___ile duct is seen to measure up to 10 mm, likely
slightly increased
as it was previously seen to measure up to 7 mm. No retained
stone is seen in
the visualized portion of the duct.
MRCP:
Mild dilation of the extrahepatic bile duct with focal caliber
change in the
distal CBD near the ampulla, without definite evidence of an
obstructing stone
or lesion. Further evaluation with EUS/ERCP is recommended.
Urine Cx negative for growth
Cdiff PCR negative
Stool Culture pending at the time of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg
intrauterine continuous
Discharge Medications:
1. Mirena (levonorgestrel) 20 mcg/24 hours ___ yrs) 52 mg
intrauterine continuous
2. Vitamin D ___ UNIT PO DAILY
3. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you are seen by your primary care
physician
___:
Home
Discharge Diagnosis:
Biliary obstruction
Possible Common bile duct abnormality
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with PMH cholecystectomy, chronic hep B,
presenting with worsening abdominal pain with ultrasound showing dilated CBD.
ERCP team requesting MRCP// eval for cause of CBD dilation
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
Lower Thorax: There are trace bilateral pleural effusions.
Liver: Liver demonstrates homogeneous signal intensity throughout, without
significant drop in signal on opposed phase imaging to suggest hepatic
steatosis. In segment 5, there is a 19 mm T2 hyperintense lesion
demonstrating mild internal enhancement, which likely represents a hemangioma
(04:20). A small cyst is seen along the periphery of segment 4 (04:22), and
in segment 7 (4:29). No suspicious hepatic lesion.
Biliary: Gallbladder is surgically absent. The extrahepatic bile duct is
slightly prominent, measuring up to 7 mm. However, there is focal caliber
change at the distal CBD close to the ampulla, where there is suggestion of a
T2 hypointense filling defect (03:20, 8:1). However, this would be atypical
in appearance for a stone. No evidence of differential enhancement or
definite obstructing lesion identified. The central intrahepatic bile ducts
are mildly prominent. The right posterior duct drains into the left hepatic
duct, a normal variant.
Pancreas: There is normal intrinsic T1 hyperintense signal throughout the
pancreas. No focal parenchymal lesions or ductal dilation.
Spleen: Spleen is normal in size, without focal lesions.
Adrenal Glands: Normal in size and shape.
Kidneys: Kidneys are normal in size and shape. No solid parenchymal lesions
are identified. There is no hydronephrosis.
Gastrointestinal Tract: Stomach is unremarkable. There is no bowel
obstruction or ascites.
Lymph Nodes: Retroperitoneal and mesenteric lymph nodes are not enlarged by
size criteria.
Vasculature: Abdominal aorta is not aneurysmal. Celiac artery, superior
mesenteric artery, and bilateral renal arteries are patent.
Osseous and Soft Tissue Structures: There is a T1 hyperintense lesion along
the superior endplate of T11, which may represent focal fat or a hemangioma.
IMPRESSION:
Mild dilation of the extrahepatic bile duct with focal caliber change in the
distal CBD near the ampulla, without definite evidence of an obstructing stone
or lesion. Further evaluation with EUS/ERCP is recommended.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Epigastric pain
temperature: 97.9
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 123.0
dbp: 81.0
level of pain: 5
level of acuity: 3.0 | ___ y/o F with PMHx of chronic Hep B, H pylori s/p treatment and
s/p laparoscopic CCY in ___ who presents with abdominal pain
with N/V, dilated biliary tree on imaging and
elevated/obstructive LFTs. MRCP shows change in caliber of
distal CBD though no obvious stones. Symptoms and lab
abnormalities resolved without intervention and pt has close
follow up planned with ERCP team for procedure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Nausea, Vomiting, Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o firefighter with Crohns disease managed
with mesalamine and mercaptopurine, and multiple SBOS in the
past year, who presents to the ED with ~20 hours of abdominal
distension, nausea, and vomiting. He has had multiple episodes
of brown-green emesis, decreased flatus, and no bowel movements
since yesterday. He denies any fevers/chills. He has been
found
on colonoscopy and CT to have primary TI disease, and was
scheduled for a right colectomy with Dr. ___ on ___.
We are consulted to assist in the management of recurrent SBO.
Past Medical History:
1. Crohns Disease- diagnosed ___.
-S/P end sigmoid colostomy at OSH in ___ due to LLQ abscess.
-S/P sigmoid colectomy with reversal of colostomy and end-end
anatamosis ___ at ___
-Last colonoscopy ___ of Crohns inflammation at 30 cm
(chronic inactive crohns) and at 60 cm (focal active colitis)
from anus
2. Rectal polyp ___. Colonic polyp ___ adenomatous with low-grade
dysplasie.
4. Esophageal ring on EGD- ___ ?Hep A
6. s/p multiple hernia repairs
7. s/p cholecystectomy ___. Right patellar bone ___ likely secondary to
steroids
Social History:
___
Family History:
F: died at ___ of emphysema. Aunt with colon ___. No IBD in
family.
Physical Exam:
VSS
General: NAD
HEENT: NCAT OP Clear MMM
CV: rrr s1s2 no mrg
Resp: CTAB
Abd: obese, soft, ntnd +BS, no organomegaly
Ext: wwp no c/c/e
Pertinent Results:
HISTORY: Abdominal pain with history of Crohn's and small-bowel
obstructions.
COMPARISON: AXR ___, CT ___.
FINDINGS:
Supine and upright views of the abdomen were obtained. There is
dilation of
small bowel to 6.5 cm in the left hemiabdomen. There is no free
air under the
diaphragm. Cholecystectomy clips and clips projecting over the
right
hemiabdomen are in place. No acute osseous abnormality is
identified.
IMPRESSION:
Findings consistent with small bowel obstruction. No definite
free air.
Findings discussed with Dr. ___ (___) by phone at 9:30pm
on ___.
The study and the report were reviewed by the staff radiologist.
___ 05:55AM BLOOD WBC-10.8# RBC-4.54* Hgb-13.9*# Hct-41.0#
MCV-90 MCH-30.6 MCHC-33.8 RDW-14.8 Plt ___
___ 08:40PM BLOOD WBC-23.4*# RBC-5.64 Hgb-17.3 Hct-51.4
MCV-91 MCH-30.7 MCHC-33.7 RDW-14.1 Plt ___
___ 08:40PM BLOOD Neuts-89.8* Lymphs-5.2* Monos-4.2 Eos-0.4
Baso-0.4
___ 05:55AM BLOOD Plt ___
___ 08:40PM BLOOD Plt ___
___ 08:40PM BLOOD ___ PTT-31.7 ___
___ 07:00AM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-139
K-4.1 Cl-104 HCO3-26 AnGap-13
___ 05:55AM BLOOD Glucose-104* UreaN-35* Creat-0.9 Na-139
K-3.9 Cl-102 HCO3-27 AnGap-14
___ 08:40PM BLOOD Glucose-154* UreaN-41* Creat-1.2 Na-137
K-4.5 Cl-95* HCO3-25 AnGap-22*
___ 05:55AM BLOOD ALT-41* AST-21 AlkPhos-59 TotBili-1.8*
___ 07:00AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1
___ 05:55AM BLOOD Albumin-3.5 Calcium-8.4 Phos-3.7 Mg-1.9
___ 08:40PM BLOOD Albumin-5.0 Calcium-10.1 Phos-4.6*#
Mg-2.2
___ 08:44PM BLOOD Lactate-2.1*
Medications on Admission:
Amlodipine 2.5', Lisinopril-HCTZ ___, Pentasa ___,
Vitamin
D, ASA 81', Mercaptopurine 75', Pantoprazole 40'
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Mercaptopurine 75 mg PO DAILY
8. Mesalamine 500 mg PO QID
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
10. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Abdominal pain with history of Crohn's and small-bowel obstructions.
COMPARISON: AXR ___, CT ___.
FINDINGS:
Supine and upright views of the abdomen were obtained. There is dilation of
small bowel to 6.5 cm in the left hemiabdomen. There is no free air under the
diaphragm. Cholecystectomy clips and clips projecting over the right
hemiabdomen are in place. No acute osseous abnormality is identified.
IMPRESSION:
Findings consistent with small bowel obstruction. No definite free air.
Findings discussed with Dr. ___ (ACS) by phone at 9:30pm on ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.3
heartrate: 108.0
resprate: 16.0
o2sat: 96.0
sbp: 123.0
dbp: 80.0
level of pain: 4
level of acuity: 3.0 | Patient was admitted to ___ Department of Surgery from the
Emergency Department. His brief hospital course is as listed.
Neuro: Patient's mental status was monitored regularly per floor
protocol. He received IV acetaminophen for pain relief. Once
tolerating oral foods and medication, he was transitioned to
oral acetaminophen.
Cardio: Patient's heart rate and blood pressures were monitored
routinely per floor protocol. He continued his home lisinopril,
amlodipine, and HCTZ. No acute issues were addressed during this
hospitalization.
Pulmonary: Patient's respiratory rate and oxygen saturation were
monitored regularly during his hospitalization. No acute issues
were addressed during this hospitalization.
GI/FEN/GU: Given patient's suspected SBO, patient received a NGT
in the ED. He was given IV fluids for hydration. Patient's
electrolytes were monitored routinely and repleted as
appropriate. Once patient had return of bowel function and his
NGT output decreased, his NGT was removed. Patient was started
on regular diet without incident prior to discharge home. His
urinary output was monitored to ensure adequate peripheral
perfusion. Patient continued his home mesalamine and
pantoprazole.
Heme: Patient's hematocrit was monitored to rule out concern for
bleeding. He continued his home aspirin.
ID: Patient's fever curve and WBC count was trended. Patient was
afebrile throughout hospitalization. Patient was given IV flagyl
and cipro until he could tolerate oral medications. He was
discharged home to continue a 7 day course of antibiotics.
PPX: Patient was given subcutaneous heparin for DVT prophylaxis.
Once patient was tolerating oral medication and nutrition, he
was discharged home with appropriate prescriptions. He will
return to service on ___ for surgery. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet / prednisone
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH afib on warfarin, CKD, DM, CHF presents after falling.
Pt was at ___ yesterday when he went to the bathroom, missed a
step, and fell on his side. He has severe pain in his L hip. He
is unsure if he hit his head. Not clear if this was a syncopal
episode as the patient has baseline cognitive impariment and is
a poor historian. He recalls being confused during this event.
Per note in OMR, he has been confused and lightheaded recently.
(Per OMR note) ___ for ___ called to
report that she has been seeing the patient for the past 6
weeks and he has become increasing pale and disoriented. Pt is
very dehydrated. He only drinks 2 cups of tea everyday. He
refuses to drink water because he doesn't like it. Today when he
checked in for his appt. he became extremely disoriented and
wandered off and got lost. He ended up falling. EMTs on-site
checked him out and his vitals were stable. Wife took him home.
___ thinks ___ should see him or speak to him about the
importance
of drinking fluids.
In the ED, initial vital signs were 0 98.8 78 158/78 20 99% 2L
Nasal Cannula. In ED, EKG showed afib with normal ventricular
response. CXR was negative. UA was negative. CT head, C-spine,
and pevlis were prelim neg for fracture or acute injury.
Patient was given morphine, zofran. Pt did not ambulate well, so
was admitted.
On the floor, T98.6 148/82 hr 84 rr 20 93RA. Pt c/o nausea and
SOB. Denies chest pain, back pain, lower ext pain, dysuria, abd
pain, diarrhea. has chr constipation
Review of Systems:
(+)
(-)
Past Medical History:
CHF, (EF 54%) with 3+ TR, and ___ MR
___ syncope with profound carotid sinus hypersensitivity
DM
chronic renal insufficiency Cr 1.7-1.9
Atrial fibrillation on warfarin and rate controlled
s/p PPM in ___ with generator change in ___, which is a single
chamber device.
PFTs showed severe mixed obstructive and restrictive defect
with long standing smoking history
BPH
polyneuropathy
cognitive impairment
___ pain
S/P PARTIAL GASTRECTOMY FOR ULCERS ___
Social History:
___
Family History:
mother- died throat cancer age ___
father - died ___, alcohol abuse
No history of immunologic disease or other cancers in family
Physical Exam:
ADMIT
Vitals- 98.6 148/82 hr 84 rr 20 93RA
General: NAD alert and oriented x3
HEENT: MMM
CV: irregular rate nl s1 s2
Lungs: CTAb bibasilar rales no wheezes/rhonchu
Abdomen: +BS soft nontender nondistended
Ext: WWP
Neuro: CN ___ intact. Upper extremities ___ strength in
biceps/triceps. Lower extremities LLE hip flexion 0-1/5, left
knee flexion ___, left dorsi/plantarflex ___ RLE ___ hip
flexion, ___ right knee flex/extension, right dorsi/plantarflex
___.
Skin: left thigh macular erythematous rash nontender, no e/o of
left sided ecchymosis from fall. Left knee and left hadn ___
digit excoriations from fall
DISCHARGE
Vitals- 98.1 126/82 hr 74 rr 18 98RA
___
General: NAD alert and oriented x3
HEENT: MMM
CV: irregular rate nl s1 s2
Lungs: CTAb bibasilar rales no wheezes/rhonchu
Abdomen: +BS soft nontender nondistended
Ext: WWP
Neuro: CN ___ intact. Upper extremities ___ strength in
biceps/triceps. Lower extremities LLE hip flexion 3+/5, left
knee extension 3+/5, left dorsi/plantarflex ___ RLE ___ hip
flexion, ___ right knee flex/extension, right dorsi/plantarflex
___.
Skin: left thigh macular erythematous rash nontender, no e/o of
left sided ecchymosis from fall. Left knee and left hadn ___
digit excoriations from fall
Pertinent Results:
ADMIT
========================
___ 10:15AM BLOOD WBC-8.4# RBC-3.83* Hgb-10.2* Hct-32.6*
MCV-85 MCH-26.7* MCHC-31.3 RDW-16.3* Plt ___
___ 10:15AM BLOOD Neuts-74.4* Lymphs-17.0* Monos-5.9
Eos-2.1 Baso-0.6
___ 08:50AM BLOOD ___
___ 10:15AM BLOOD ___ PTT-36.0 ___
___ 10:15AM BLOOD Glucose-123* UreaN-36* Creat-1.8* Na-135
K-4.3 Cl-102 HCO3-23 AnGap-14
___ 07:40AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.0
___ 10:15AM BLOOD VitB12-GREATER TH
DISCHARGE
==========================
___ 07:15AM BLOOD WBC-6.5 RBC-3.65* Hgb-9.9* Hct-30.7*
MCV-84 MCH-27.1 MCHC-32.3 RDW-16.4* Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-34.0 ___
___ 07:15AM BLOOD Glucose-109* UreaN-31* Creat-1.5* Na-135
K-4.3 Cl-104 HCO3-22 AnGap-13
___ 07:15AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0
IMAGING
===========================
___ CT C-SPINE without Con
There is no evidence of fracture or acute malalignment in the
cervical spine. Multilevel multifactorial degenerative changes
are again noted with prominent anterior osteophyte formation,
more extensive than on the most recent CT of the neck from ___, as well as persistent ossification of the posterior
longitudinal ligament (OPLL) involving the C3-C4 through C7
levels with a similar degree of spinal canal narrowing, most
significant at the C3-C4 level where the spinal canal narrowing
is at least moderate, along with severe right neural foraminal
narrowing due to facet arthropathy at the same level.
No prevertebral soft tissue swelling is present. No
lymphadenopathy is seen.
The visualized lung apices are unremarkable.
IMPRESSION:
1. No fracture or acute malalignment in the cervical spine.
2. Multilevel degenerative changes of the cervical spine, as
described above resulting in at least moderate canal narrowing.
___ CT HEAD without Con
There is no evidence of intracranial hemorrhage, edema, mass,
mass effect or acute vascular territorial infarction.
Persistent enlargement of the lateral and ___ ventricles is
unchanged in extent since the prior study, and is
disproportionate to the degree of sulcal prominence, reflecting
either preferential central atrophy or communicating
hydrocephalus. Periventricular white matter hypodensities are
unchanged, and reflect chronic small vessel ischemic disease.
The basal cisterns appear patent and there is preservation of
the gray-white matter differentiation. There is no fracture
identified.
The visualized paranasal sinuses, mastoid air cells and middle
ear cavities are essentially clear. The globes are intact
bilaterally. There are no cranial or facial soft tissue
abnormalities present.
IMPRESSION:
1. No acute intracranial process.
2. Persistent ventriculomegaly, reflecting either preferential
central atrophy or communicating hydrocephalus, is unchanged in
extent since ___.
___
PELVIS AP
IMPRESSION:
Though there is no radiographic evidence for displaced fracture
of the left hip, given the clinical history of inability to bear
weight after sustaining a fall, an occult fracture cannot be
completely excluded and further imaging is recommended if
clinical suspicion for fracture exists.
___ HIP Unilat Min 2 Views
Though there is no radiographic evidence for displaced fracture
of the left hip, given the clinical history of inability to bear
weight after sustaining a fall, an occult fracture cannot be
completely excluded and further imaging is recommended if
clinical suspicion for fracture exists.
___ CHEST
Single supine view of the chest. Left chest wall single lead
pacing device is again noted. The lungs are grossly clear
noting some respiratory motion which limits detailed evaluation.
Cardiomediastinal silhouette is unchanged with possible mild
cardiomegaly. No definite displaced fracture identified.
Surgical clips project over the upper abdomen. Likely
posttraumatic changes seen at the distal right clavicle and
degenerative changes at the right
shoulder.
IMPRESSION:
No definite acute cardiopulmonary process.
___
CT PELVIS WITHOUT CON
IMPRESSION:
1. No evidence of fracture or abnormal alignment of the left
hip.
2. Degenerative changes of the bilateral femoroacetabular
joints, sacroiliac joints and lumbar spine, as described above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Doxazosin 4 mg PO HS
3. Furosemide 20 mg PO DAILY
4. Warfarin 4 mg PO DAILY16
5. Cyanocobalamin 1000 mcg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
7. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN rash on
chest, groin, face
8. Ketoconazole 2% 1 Appl TP QAM face, chest, groin
9. sulfacetamide sodium *NF* 10 % Topical daily:prn face and
chest
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID body
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypovolemia
Orthostatis
Shingles
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Pain status post fall with severe left hip pain.
COMPARISON: Comparison is made to radiographs of the hips from ___
as well as ___.
FINDINGS:
There is no evidence of displaced fracture or abnormal alignment within the
hip joints. The trabecular pattern of the bilateral femurs are normal.
Osteophytes are present and degenerative changes are seen at the bilateral
femoroacetabular joints. Spurring is present of the left superior acetabulum,
as before. There is no diastases of the pubic symphysis and sacroiliac
joints. Degenerative changes are again seen within the lower lumbar spine.
IMPRESSION:
Though there is no radiographic evidence for displaced fracture of the left
hip, given the clinical history of inability to bear weight after sustaining a
fall, an occult fracture cannot be completely excluded and further imaging is
recommended if clinical suspicion for fracture exists.
Radiology Report
HISTORY: ___ male with fall and mid chest discomfort.
COMPARISON: ___.
FINDINGS:
Single supine view of the chest. Left chest wall single lead pacing device is
again noted. The lungs are grossly clear noting some respiratory motion which
limits detailed evaluation. Cardiomediastinal silhouette is unchanged with
possible mild cardiomegaly. No definite displaced fracture identified.
Surgical clips project over the upper abdomen. Likely posttraumatic changes
seen at the distal right clavicle and degenerative changes at the right
shoulder.
IMPRESSION:
No definite acute cardiopulmonary process.
Radiology Report
HISTORY: Fall with mild headache. Patient on warfarin. Evaluation for acute
injury.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of intravenous contrast. Reformatted coronal,
sagittal and thin slice bone images were reviewed.
COMPARISON: Comparison is made to CT of the head from ___ as well
as CT of the head from ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, mass, mass effect or
acute vascular territorial infarction. Persistent enlargement of the lateral
and ___ ventricles is unchanged in extent since the prior study, and is
disproportionate to the degree of sulcal prominence, reflecting either
preferential central atrophy or communicating hydrocephalus. Periventricular
white matter hypodensities are unchanged, and reflect chronic small vessel
ischemic disease. The basal cisterns appear patent and there is preservation
of the gray-white matter differentiation. There is no fracture identified.
The visualized paranasal sinuses, mastoid air cells and middle ear cavities
are essentially clear. The globes are intact bilaterally. There are no
cranial or facial soft tissue abnormalities present.
IMPRESSION:
1. No acute intracranial process.
2. Persistent ventriculomegaly, reflecting either preferential central atrophy
or communicating hydrocephalus, is unchanged in extent since ___.
Radiology Report
HISTORY: Fall with mild headaches. Evaluation for acute injury.
TECHNIQUE: Axial helical MDCT images were obtained through the cervical spine
without the use of intravenous contrast. Reformatted coronal and sagittal
images were also reviewed.
COMPARISON: Comparison is made to CT of the neck from ___ as well as
CT of the cervical spine from ___.
FINDINGS:
There is no evidence of fracture or acute malalignment in the cervical spine.
Multilevel multifactorial degenerative changes are again noted with prominent
anterior osteophyte formation, more extensive than on the most recent CT of
the neck from ___, as well as persistent ossification of the
posterior longitudinal ligament (OPLL) involving the C3-C4 through C7 levels
with a similar degree of spinal canal narrowing, most significant at the C3-C4
level where the spinal canal narrowing is at least moderate, along with severe
right neural foraminal narrowing due to facet arthropathy at the same level.
No prevertebral soft tissue swelling is present. No lymphadenopathy is seen.
The visualized lung apices are unremarkable.
IMPRESSION:
1. No fracture or acute malalignment in the cervical spine.
2. Multilevel degenerative changes of the cervical spine, as described above
resulting in at least moderate canal narrowing.
Radiology Report
HISTORY: ___ male with left hip pain after fall. Evaluation for
possible hip fracture.
TECHNIQUE: MDCT images were obtained through the pelvis without the
administration of oral or IV contrast. Reformatted coronal and sagittal
images were also reviewed.
COMPARISON: Comparison is made to radiographs of the left hip from ___ as well as ___.
FINDINGS:
There is no evidence of fracture or abnormal alignment. The bilateral femoral
heads are well seated within the acetabulua bilaterally. There is no
diastasis of the pubic symphysis or sacroiliac joints. Degenerative changes
and fusion with osteophyte formation of the bilateral sacroiliac joints is
present. There is redemonstration of spurring and subchondral sclerosis of the
bilateral femoroacetabular joints, consistent with degenerative change.
Enthesopathy of the right greater trochanter is again seen. No lytic or
sclerotic lesions suspicious for malignancy is present. Additionally,
degenerative changes are noted within the lumbar spine seen with anterior
osteophyte formation at the L5 level. No significant soft tissue swelling is
noted.
The bladder is distended, and is unremarkable in appearance. Atherosclerotic
calcifications are noted within the iliac arteries. The rectum and sigmoid
appear unremarkable and hyperdense pill fragments are seen within the sigmoid.
No pelvic sidewall or inguinal lymphadenopathy is present.
IMPRESSION:
1. No evidence of fracture or abnormal alignment of the left hip.
2. Degenerative changes of the bilateral femoroacetabular joints, sacroiliac
joints and lumbar spine, as described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with SYNCOPE AND COLLAPSE, HERPES ZOSTER NOS, HYPERTENSION NOS, CARDIAC PACEMAKER STATUS
temperature: 98.8
heartrate: 78.0
resprate: 20.0
o2sat: 99.0
sbp: 158.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | Assessment and Plan:
___ with PMH DM, afib on coumadin, CKD presents after poor PO
intake and sustaining fall at ___ with subsequent hip pain s/p
negative CT head / neck / pelvis but failed to ambulate safely
so admitted for placement.
# Hypovolemia: Pt presented orthostatic and was bolused one time
each day of admission. Pt's wife reports that he is no longer
drinking fluids, only drinking tea. "He dislikes the taste of
water". Furosemide was held during hospitalization and will be
held on discharge due to poor PO intake and admission with
orthostasis.
# Left leg weakness / pain: Pt presented with profound left leg
weakness, and while he never c/o pain, he actually would jolt
upright when his left hip was externally rotated. He was given
standing PO tylenol, and encouraged to work daily with ___,
during which he improved on his weight bearing and ambulation.
Initially team considered obtained MRI left hip to assess for
muscle transection or nerve damage from fall, however, since pt
was spontaneously improving with ___, determined that pt was
actually not weak but limited by pain.
no e/o of left pelvis fx, no paresthesias or pain currently,
weak mostly in hip adn knee. Weakness worse after fall. Dorsal
column neuropathy may be related to unsteadiness. currently
unsteady but able to bare weight
- check B12, CK
- ___ c/s
# Mechanical fall: Pt reports walking through a door and there
not being a step, so he fell. He denies LOC. He fell on his left
side, and extensive CT imaging of left hip / pelvis/ head / neck
are not concerning for fracture. Pt also has h/o of carotid
hypersensitivity, but based on hx this is unlikely as pt reports
losing balance after stepping through a door.
# Shingles: Pt presents with paninful lesions behind left leg
without e/o vescicles. Since the time course of shingles is
unknown, team did not feel that acyclovir or other antiviral
would change duration of lesions or alter likelihood of
postherpetic neuralgia.
# DOE: Pt initially complained of dyspnea on exertion, which was
thought to be ___ to pulm htn possibly with a component of COPD
given smoking hx. Pt was never wheezing or poorly moving air or
clinically with rales on exam. He was also never hypoxic or SOB
when working with ___.
# Afib on coumadin: CHADS 3. Pt was continued on atenolol 25mg
PO qd and was continued on warfarin 4mg PO qd.
# CKD: (baseline 1.7-1.9) Pt was given IVF for orthostasis on
admission and Cr downtrended to 1.5
# DM: not on insulin at home, but has been on humalog ISS during
hospitalizations
# Anemia: baseline hct 32. Stable
# BPH: Pt was continued on home doxazosin 4 mg tablet.
# CHF EF 54%: Held furosemide for poor PO intake, and will hold
on discharge pending clinical improvement and PO intake. Was
taking furosemide 20 mg tablet.
# B12 Def ___ gastrectomy: B12 was > ___.
# Code: Full (discussed with patient)
# Communication: Patient
# Emergency Contact: Ms. ___ ___
TRANSITION ISSUES
# consider resuming furosemide as was stopped on admission ___
orthostasis
# Pt does not c/o pain, so do not rely on his hx to tell ___ msk
pain |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Gastroenteritis, Transaminitis, Hemolysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Male who presents with 8 days of fevers to 102,
nausea/vomitting, hemolysis and transaminitis. The patient is at
baseline healthy, when 8 days prior to admission he notes
lethargy, nasuea and vomitting. He was at college, and went to
the ___ health ___, who performed a liver scan which
was reportedly normal. He continued with his symptoms, after
returning home for ___. He denies knowing others with
the same symptoms. He also describes headaches, palpitations and
sore throat along with the other symptoms. He notes that several
days prior to admission his urine became darkly colored.
He came to the ___ ED on ___ where he was noted with
splenomegally on imaging and transaminitis. An LP was negative
and a rapid strep test was also negative. He was discharged with
a presumed diagnosis of mononucleosis. He returned on ___
with continue nausea and vomitting and fevers. He was noted in
the ED with fevers to 102. He was agressively hydrated, along
with IV antiemetics with good result. He reports some
improvement in his symptoms.
Past Medical History:
Kidney surgery as child for repair of congenital defect in the
collecting system
Social History:
___
Family History:
No liver or hematologic diseases
Physical Exam:
ROS:
GEN: + fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding, + Sore Throat
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, + Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 102.9, 106/55, 107, 18, 97%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, Kissing Tonsils
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 05:38AM BLOOD WBC-5.1 RBC-3.74* Hgb-11.8* Hct-32.5*
MCV-87 MCH-31.5 MCHC-36.3* RDW-13.5 Plt ___
___ 06:45AM BLOOD WBC-5.4 RBC-4.06* Hgb-12.5* Hct-35.1*
MCV-86 MCH-30.7 MCHC-35.5* RDW-13.4 Plt ___
___ 05:40AM BLOOD WBC-6.5 RBC-4.18* Hgb-12.9* Hct-35.9*
MCV-86 MCH-30.8 MCHC-35.8* RDW-13.2 Plt ___
___ 05:38AM BLOOD Neuts-34* Bands-0 ___ Monos-13*
Eos-0 Baso-0 Atyps-14* ___ Myelos-0
___ 06:45AM BLOOD Neuts-62 Bands-0 ___ Monos-7 Eos-1
Baso-0 ___ Myelos-0
___:40AM BLOOD Neuts-53 Bands-3 ___ Monos-10 Eos-0
Baso-0 Atyps-10* Metas-1* Myelos-0
___ 05:38AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-1+
___ 06:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:38AM BLOOD ___ PTT-39.2* ___
___ 06:00AM BLOOD ___ PTT-38.1* ___
___ 05:38AM BLOOD ___ 06:45AM BLOOD Parst S-NEGATIVE
___ 05:38AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-135 K-3.5
Cl-102 HCO3-22 AnGap-15
___ 06:45AM BLOOD Glucose-102* UreaN-10 Creat-0.9 Na-135
K-3.5 Cl-99 HCO3-25 AnGap-15
___ 05:38AM BLOOD ALT-244* AST-254* LD(LDH)-805* AlkPhos-51
TotBili-3.3*
___ 06:45AM BLOOD ALT-180* AST-170* LD(___)-708* AlkPhos-50
TotBili-2.6* DirBili-1.3* IndBili-1.3
___ 05:40AM BLOOD ALT-121* AST-145* AlkPhos-48 TotBili-1.7*
___ 05:38AM BLOOD Albumin-3.5 Calcium-8.0* Phos-1.7* Mg-1.9
___ 06:45AM BLOOD Albumin-3.9
___ 05:40AM BLOOD Albumin-4.3 Calcium-9.0 Phos-2.9 Mg-1.9
___ 06:45AM BLOOD Hapto-<5*
___ 06:45AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND
IgM HAV-PND
___ 07:06AM BLOOD Lactate-1.3
___ 05:10PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 02:23PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-PND
___ 02:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
___ 02:00PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-0
___ 07:18AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
___ Macroph-40
___ 07:18AM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-58
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
Blood (EBV)
___ VIRUS VCA-IgG AB (Pending):
___ VIRUS EBNA IgG AB (Pending):
___ VIRUS VCA-IgM AB (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
Blood (CMV AB)
CMV IgG ANTIBODY (Pending):
CMV IgM ANTIBODY (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
SEROLOGY/BLOOD
LYME SEROLOGY (Pending):
___ 2:00 pm URINE
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
___ 5:57 am SEROLOGY/BLOOD
ADDED FROM ___ ON ___ AT 09:02.
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
7:27 AM
IMPRESSION:
1. Trace sludge within an otherwise unremarkable gallbladder
without evidence of cholecystitis.
2. Prominent splenomegaly of unclear etiology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. OSELTAMivir 75 mg PO Q12H Duration: 5 Days
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*6 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: EBV mono, low grade DIC, hepatitis, flu
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Cough, questionable pneumonia.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: A single portable view is provided. Normal lung volumes. Azygos
lobe as anatomical variant. Normal size of the cardiac silhouette. No
pleural effusions. No pulmonary edema. No pneumonia.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NAUSEA/VOMITING
Diagnosed with FEVER, UNSPECIFIED, HEADACHE
temperature: 100.1
heartrate: 119.0
resprate: 22.0
o2sat: 97.0
sbp: 104.0
dbp: 51.0
level of pain: 0
level of acuity: 3.0 | ___ yo M w/ no significant PMH who presents with fevers, n/v,
splenomegaly, transaminitis, elev direct bili and is EBV IgM pos
and influenza A positive.
#EBV Mononucleosis, Transaminitis: He initially presented with
GI symotoms (nausea and vomitting) most likely related to
hepatitis but over hosp course dev pharyngitisn exam with
enlarged tonsils. EBV IgM positive with ___, smear with
atypical lymphs. CMV Ab neg. Pt had transaminitis (AST ALT
300s), elev bili (up to 3), splenomegaly and also had low grade
DIC (slightly elevated INR and PTT) all related to EBV. Initial
concern for autoimmune hemoltic anemia in setting of low hapto
and elev LDH and elev bili (though direct higher than indirect)
and coombs and agglutinin were somewhat inconclusive and most
likely there was a low grade hemolytic anemia. EBV can cause an
autoimmune hemolytic anemia (anti-i). Ferritin in the 2000s
making HLH (EBV can cause HLH) unlikely. Heme/onc and ID
involved in his care. He was given zofran, IVF as supportive
measures. He was told to avoid contact sports bc of splenomegaly
and risk of splenic rupture.
#Influenza A:
He was started on tamiflu day ___ w/ plan to treat for 5 d
#Coagulopathy, Diseminated Intravascular Coagulation, Hemolysis:
slightly elev INR and PTT but stable, this was likely a low
grade DIC (elev D dimer, FDP, though fibrinogen normal) combined
w/ acute hepatitis. Hematology was consulted. He never required
transfusions |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Amoxicillin / clindamycin
Attending: ___.
Chief Complaint:
difficulty writing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F w PMHx of HLD, depression, and
rheumatoid arthritis who presents to ___ ED after sudden onset
of difficulty writing and visual disturbance - her symptoms
resolved within ~1 hour. A code stroke was called upon arrival.
Ms. ___ has significant difficulty in recalling the events
prior to her admission, so much of the history is supplied by
her
partner, ___. They both agree that Ms. ___ was "exhausted"
today, more so than normal. They were at a camera shop around
3:30PM when Ms. ___ tried to write a check to pay for their
items. She found she had great difficulty writing and her
handwriting was extremely messy. She was able to grip the pen
and
did not feel weak, persay, though her hand "wasn't doing what I
wanted it to." With some effort, she was able to write the check
and the clerk was able to read it.
She and ___ got in the car to drive to Ms. ___ previously
scheduled doctor's appointment. ___ was driving. About 5
minutes after leaving the store, Ms. ___ began to complain of
a mild left sided headache and associated blurry vision on her
right side. She did not cover one eye to see if the blurry
vision
was monocular or binocular.
At her doctor's appointment today, Ms. ___ recounted the
story
to the physician who did ___ screening examination for stroke. Ms.
___ deficits had apparently resolved, but the physician
referred Ms. ___ to ___ "to get an MRI."
Currently, Ms. ___ states that her headache and blurry vision
have resolved - she estimates that they lasted ~1 hour. Her
handwriting is also back to her baseline and she does not
endorse
any difficulty controlling the right hand. She denies any
associated weakness, numbness, difficulty speaking or
comprehending speech.
Notably, Ms. ___ has been suffering from "severe exhaustion"
for at least the past week. Her partner and her friends having
been concerned about her and urged her to make the above
doctor's
appointment. Ms. ___ partner also states that Ms. ___
memory has been quite poor for sometime - though she believes it
was worse today.
Ms. ___ reports a similar event ___ years ago. She was
admitted
to ___ with the presenting complaint of transient total
vision loss. She is unsure if she was diagnosed with a TIA. When
it was time for her to be discharged, she was "completely
unable"
to sign her name on the discharge sheet. The event differs from
her current event because at that time she was unable to write
any words down at all. It is unclear what additional work-up was
done at that time.
Ms. ___ also reports a long standing problem with memory. She
has been evaluated several times due to concern for Alzheimer's
disease. She tells me that several years ago she was evaluated
by
a neurologist and told that her symptoms were not consistent
with
Alzheimer's disease.
Past Medical History:
- HLD
- depression
- rheumatoid arthritis
- vitamin D deficiency
- GERD
- sleep apnea on CPAP
- prior ASD repair x2
- ?TIA for visual loss ___ years ago, seen at ___
Social History:
___
Family History:
Father - ___
Mother - ___ Disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T97.9 HR64 BP110/70 RR18 Sat97%RA
GEN - obese female, pleasant and cooperative, NAD
HEENT - NC/AT, MMM
NECK - supple, good ROM
CV - RRR
RESP - normal WOB
ABD - obese, soft, NT, ND
EXTR - warm and well perfused
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
NEUROLOGICAL EXAMINATION:
MS - awake and alert; oriented to self, place, and date (says
___ or ___ able to recite MOYB slowly but
accurately; great difficulty recounting recent medical history,
is vague in supplying details and ask partner for help with
answer many simple questions; speech is otherwise fluent, with
intact naming, reading, and comprehension; she is able to write
a
full sentence and believes the handwriting appears completely
normal; there is no dysarthria; no evidence of apraxia or
neglect
CN - [II] PERRL 4->2 brisk. VF full to number counting. [III,
IV,
VI] EOMI, no nystagmus. [V] V1-V3 without deficits to light
touch
bilaterally. [VII] There is very mild R eye ptosis vs redundant
skin, though her partner states that she has not noticed this
before; symmetric activation. [VIII] Hearing intact to voice.
[IX, X] Palate elevation symmetric. [XI] SCM/Trapezius strength
___ bilaterally. [XII] Tongue midline with full ROM.
MOTOR - Normal bulk and tone; No pronation, no drift - though
she
is unable to fully supinate the RUE d/t long standing orthopedic
injury.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5 5 R
5 5 5 5 5 5 5 5 5 5
SENSORY - No deficits to light touch or pinprick throughout.
REFLEXES -
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response mute bilaterally.
COORD - No dysmetria on FNF bilaterally; good speed and intact
cadence with rapid alternating movements.
GAIT - Normal initiation, narrow base; normal stride length and
arm sway.
=======================================
DISCHARGE PHYSICAL EXAM:
Tm 97.8 ___ 53-57 20 99% RA
Alert, interactive, speech fluent, no dysarthria. Able to recall
events of admission but trouble remembering the details
surrounding her headache and vision changes. Able to say the
months of the year backwards. Able to calculate $1.75 is 7
quarters. Registers ___ objects, recalls ___ at 5 minutes and
___ with prompting. No graphesthesia.
CN: EOMI, no nystagmus, VFF, smile symmetric
Motor: ___
Reflexes: 2 in all but achilles which is 1, symmetric
Toes down
No dysmetria on FNF
Pertinent Results:
ADMISSION LABS:
___ 08:00PM BLOOD WBC-7.0 RBC-4.71 Hgb-14.0 Hct-43.1 MCV-92
MCH-29.7 MCHC-32.5 RDW-13.3 RDWSD-45.1 Plt ___
___ 08:00PM BLOOD Neuts-80.3* Lymphs-12.2* Monos-5.3
Eos-0.6* Baso-0.6 Im ___ AbsNeut-5.62 AbsLymp-0.85*
AbsMono-0.37 AbsEos-0.04 AbsBaso-0.04
___ 08:00PM BLOOD ___ PTT-32.3 ___
___ 08:00PM BLOOD Glucose-153* UreaN-17 Creat-0.8 Na-139
K-4.9 Cl-104 HCO3-26 AnGap-14
___ 08:00PM BLOOD ALT-17 AST-20 AlkPhos-56 TotBili-0.3
___ 08:00PM BLOOD cTropnT-<0.01
___ 05:26AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:00PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.6 Mg-2.1
___ 05:26AM BLOOD VitB12-PND Folate-PND
___ 08:17PM BLOOD %HbA1c-6.5* eAG-140*
___ 05:26AM BLOOD Triglyc-132 HDL-67 CHOL/HD-2.7 LDLcalc-91
___ 08:00PM BLOOD TSH-0.67
___ 08:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
IMAGING:
CT HEAD ___:
1. No acute intracranial process.
CXR ___:
No acute cardiopulmonary process. No significant interval
change.
CTA HEAD AND NECK ___:
1. Normal head and neck CTA.
2. No acute intracranial abnormality.
3. Interval increase in the size of bilateral thyroid nodules.
Further
evaluation with ultrasound of the thyroid can be performed.
TTE ___:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF = 60%). The right ventricular
free wall thickness is normal. The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve is not well seen. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
MRI BRAIN (PRELIM) ___:
1. No evidence of infarction.
2. Similar appearance of non-specific periventricular and
subcortical white matter T2/FLAIR hyperintensities, suggestive
of chronic small vessel ischemic changes.
3. Unchanged appearance of punctate foci of GRE susceptibility
in the right frontal white matter, which may represent vessels
or a sequela or prior hemorrhage.
DISCHARGE LABS:
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
3. Furosemide 40 mg PO DAILY:PRN peripheral edema
4. Lorazepam 0.5 mg PO DAILY:PRN anxiety
5. Escitalopram Oxalate 20 mg PO DAILY
6. PredniSONE 15 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
9. Zolpidem Tartrate 5 mg PO QHS:PRN anxiety
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Escitalopram Oxalate 20 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. PredniSONE 15 mg PO DAILY
5. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
6. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
7. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
8. Furosemide 40 mg PO DAILY:PRN peripheral edema
9. Lorazepam 0.5 mg PO DAILY:PRN anxiety
10. Zolpidem Tartrate 5 mg PO QHS:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Possible TIA
Secondary diagnosis:
Hyperlipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ED CODE STROKE ONLY CT Q13 CT HEAD
INDICATION: History: ___ with acute onset inability to write, vison change
// eval for infarct
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformats were also examined.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 55.8 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline shift, mass
effect, or acute large vascular territorial infarct. Ventricles and sulci are
mildly prominent, suggestive of age-related involutional changes. Gray-white
differentiation is preserved.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with acute onset difficulty writing, eval for
infarct.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 81.7 mGy (Head) DLP =
40.8 mGy-cm.
4) Spiral Acquisition 5.5 s, 42.9 cm; CTDIvol = 35.4 mGy (Head) DLP =
1,518.0 mGy-cm.
Total DLP (Head) = 1,559 mGy-cm.
COMPARISON: Head CT from ___, MR MRA of the brain from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The thyroid gland is enlarged
with hypointense nodule in the left lobe measuring 2.7 x 2.6 cm and in the
right lobe measuring 2.7 x 2 cm. These nodules have increased in size
compared to the prior CT chest from ___. Further evaluation
with ultrasound of the thyroid should be performed. Mild degenerative changes
involving the visualized cervical spine. There is no lymphadenopathy by CT
size criteria.
IMPRESSION:
1. Normal head and neck CTA.
2. No acute intracranial abnormality.
3. Interval increase in the size of bilateral thyroid nodules. Further
evaluation with ultrasound of the thyroid can be performed.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with difficulty writing and visual disturbance
// TIA eval
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ head/neck CTA.
___ head/neck MRA, and brain MRI
FINDINGS:
The study is motion degraded. Within these confines:
There is no evidence of edema, masses, mass effect, midline shift or
infarction. Again noted are two small foci of T2/FLAIR periventricular and
subcortical white matter hyperintensities in the left parietal region (12:15),
which is similar in appearance compared to the ___ MRI, and may represent
chronic small vessel ischemic changes. Additional note is made of two
punctate foci of GRE susceptibility in the deep white matter of the right
frontal lobe (11:18, 19) that may represent vessels or a sequela of prior
hemorrhage, but also unchanged from ___. Previously mentioned tiny T2
hyperintense/T1 hypointense focus in the left cerebellum may represent
prominent perivascular space versus prior lacunar infarct (13:3, 12:3).
Ventricles and sulci are prominent, suggestive of age-related involutional
changes.
Major intracranial vascular flow voids are preserved. Minimal mucosal
thickening in the ethmoid air cells bilaterally. Remainder of the visualized
paranasal sinuses are well aerated. Trace fluid signal is seen in the right
mastoid tip (13:6). Left mastoid air cells are clear. Orbits are
unremarkable.
IMPRESSION:
1. No evidence of infarction.
2. Similar appearance of non-specific periventricular and subcortical white
matter T2/FLAIR hyperintensities, suggestive of chronic small vessel ischemic
changes.
3. Unchanged appearance of punctate foci of GRE susceptibility in the right
frontal white matter, which may represent vessels or a sequela or prior
hemorrhage.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with ams // eval for infection
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy. Cardiac and mediastinal silhouettes
are stable. Left mid lung with linear atelectasis/scarring is stable. No
focal consolidation is seen. There is no pleural effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process. No significant interval change.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CODE STROKE
Diagnosed with OTHER MALAISE AND FATIGUE, VISUAL DISTURBANCES NEC, HEADACHE
temperature: 97.9
heartrate: 64.0
resprate: 18.0
o2sat: 97.0
sbp: 110.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ y/o F with a PMHx of HLD, depression, and
rheumatoid arthritis on Prednisone who presented to ___ ED
after sudden onset of difficulty writing and visual disturbance
which resolved after 1 hour concerning for possible TIA.
# Possible TIA: Ms. ___ reported symptoms that her hand
wasn't doing what she wanted it to do but no focal weakness or
difficulty with anything else besides writing a check. She also
had difficulty remembering the details surrounding the event.
Given these symptoms and the pecuiliar story, she was worked up
for a possible TIA. Stroke risk factors include: HbA1c 6.5 and
cholesterol panel as follows: HDL 67, LDL 91 and triglycerides
132. She had CTA and MRI which showed patent vasculature and no
evidence of stroke. She was started on aspirin 81mg. She had a
TTE which did now show any thrombus. Tele showed NSR. She was
discharged with plans to record her heart rhythm with ___ of
Hearts monitor. It is not clear that this episode was a TIA but
given her risk factors and possible prior TIA in the past, she
should continue on aspirin and be followed closely for further
symptoms.
# Memory impairment: The only finding on exam was poor recall,
specifically poor retrieval. She was able to register and store
3 objects. Vitamin B12 and folate were sent but were pending on
discharge. TSH was normal. She will need ongoing neurology
follow-up for this issue.
# Depression: Patient was continuted on Escitalopram Oxalate 20
mg PO/NG DAILY
# Hyperlipidemia: Patient was continued on Atorvastatin 10 mg
PO/NG QPM
# Rheumatoid arthritis: Patient was continued on PredniSONE 15
mg PO/NG DAILY
Transitional issues:
- endorsed memory problems and had difficulty with memory
retrival on exam, not storage. Will need ongoing work-up
- f/u ___ of hearts data
- f/u vitamin b12, folate levels
- will need diabetes treatment: HbA1c 6.5
- repeat UA, had trace protein and 3 rbcs
- f/u final read of mRI
- may need thyroid ultrasound, had bilateral thyroid nodules on
CTA (TSH 0.67)
- HCP: ___ (partner) ___
- Code: presumed FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
epinephrine / Codeine / Zoloft
Attending: ___.
Chief Complaint:
episodes of heart racing and palpitations followed by
unresponsiveness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year-old right-handed woman with a past
medical history of migraines, renal stones and possible POTS
(postural orthostatic tachycardia syndrome) who was admitted for
recurrent episodes of loss of consciousness. This history is
obtained from discussion with the patient and data from ___.
Other records are not available for review.
She reports that she was previously healthy until ___.
At that time she developed an obstructing kidney stone. The
stone
was removed and a stent was placed. Immediately following the
procedure, Ms. ___ developed symptoms of her heart racing
every time she would stand up. She called her urologist who
instructed her to "take it easy" for a couple of weeks, however
her symptoms persisted. Her symptoms were and have remained very
stereotyped. Within a few minutes of standing, she develops a
sensation that her heart is racing. She has measured her HR in
the past and states that once the HR is > 120 bpm, she feels
palpitations. She will also experience a sensation of chest
pressure and shortness of breath "like I just ran up a
mountain".
She will then feel "tingling and numbness" in her hands and feet
symmetrically followed by "tingling" starting at the base of her
neck. These facial paresthesias will rapidly spread up to her
mouth at which point she will be unable to speak. She will bit
her lip frequently voluntarily but will be unable to produce
sounds. She remains able to hear others speaking to her. The
tingling will then spread to her nose at which point she becomes
unresponsive.
The duration of the unresponsiveness may range from 5 minutes to
45 minutes. She has not had abnormal limb movements, gaze
deviation, incontinence or tongue biting in the past. She states
that at the rehab facility, they have tried to revive her using
pain, cold, laying her flat, and using ammonia all without
effect. When she regains consciousness, she is confused only for
less than a minute at most and is then aware of her
surroundings.
In the more recent months, she has begun to have "low oxygen"
during the episodes, although this has not been a problem in the
past.
There was no other prodrome, exposure, illness or other
precipitating factor aside from the renal stone removal and
stenting. Of note, she had a prior renal stone about ___ years ago
which was removed without sequelae.
Triggers: standing, exercise, washing her hair (although she is
not certain if this is due to the prolonged standing in the
shower). She does not feel that hot environments or eating
trigger symptoms. Ms. ___ has experienced these episodes
from
sitting in the past as well.
Alleviating factors: lying down, her current medication regimen
(Florinef, midodrine, metoprolol and pyridostigmine). She does
not recall the sequence of these medication trials and believes
that they were started sequentially. She states that did not
recall feeling any improvement until the entire regimen was
initiated. With this regimen, she has been able to stand up for
a
longer duration without developing symptoms (max 8 minutes)
Prior work-up: She states that she was admitted for EEG LTM in
the past and several events were captured without any identified
abnormality. She was evaluated by a cardiologist who did a tilt
table test and diagnosed her with POTS. She also believes that
she has had an echocardiogram which she believes was normal. She
has not had any recent brain imaging, but believes that she may
have had an MRI in the past when she developed migraines.
Prior treatment: as above. She was also prescribed salt tablets
and instructed to have 10 grams of sodium in her daily diet but
has not done this.
Associated symptoms: as above. Intermittent tunnel vision, this
does not always occur with the episodes. She also feels that
her
legs feel tired at times. She denies feelings of anxiety or
impending doom.
During ANS testing on ___ Ms. ___ had one of her typical
events. She became unresponsive to verbal stimuli during the
tilt
up portion of the test. Her BP remained elevated and she had a
sinus tachycardia. After she was tilted down, her eye lids
fluttered and there was resistance to eyelid opening. She did
not
respond to verbal or noxious stimulus. There was no gaze
deviation. Pupils were dilated (5 mm) and her O2 sat was as low
as 79% on RA but increased with Ambu bag. BG was 96. A code was
called and the event lasted 5 minutes after which she began to
respond to voice and was fully oriented. There was no abnormal
limb movements, tongue laceration or incontinence. She was taken
to the ED and then admitted for LTM.
Past Medical History:
- migraines starting after hysterectomy
- s/p hysterectomy
- s/p bladder suspension surgery
- s/p kidney stone surgery with stenting
- loss of consciousness after receiving "Novocaine and
epinephrine" at the dentist x 2. She reports that she had
received the injection of both medications and then used the
bathroom after which she had LOC. EMS was called. She was told
by
the dentist that the LOC was likely secondary to the
epinephrine.
Social History:
___
Family History:
-mother: HTN, HLD
-father: ___, prostate CA
-sister: anorexia, migraines
Physical Exam:
Vitals: R: 15
-Supine: 125/65 HR 60's
-Standing after 4 minutes: (patient asymptomatic) BP 135/60 HR
70's
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no distal edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia or
neglect.
CN
I: not tested
II,III: VFF to confrontation, pupils 5mm->2mm bilaterally
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
XI: SCM/trapezeii ___ bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone, no rigidity; no asterixis or
myoclonus. No pronator drift.
Delt Bi Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 ___ 5 5 5
R 5 ___ 5 5 5
IP Quad ___ PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 ___
R 5 5 5 ___
Reflex: No clonus
Bi Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L ___ 2 ___ Flexor
R ___ 2 ___ Flexor
-Sensory: No deficits to light touch
Decreased pinprick and cold sensation up to bellow the knees
bilaterally. Minimally decreased vibratory sense at the toes
bilaterally. Normal proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: testing deferred given patient history
-Romberg: absent
DISCHARGE EXAM: unchanged, distal small fiber neuropathy in ___
Pertinent Results:
___ 01:40PM BLOOD WBC-6.6 RBC-4.70 Hgb-15.4 Hct-45.2 MCV-96
MCH-32.7* MCHC-34.0 RDW-12.8 Plt ___
___ 01:40PM BLOOD Neuts-70.3* ___ Monos-4.0 Eos-1.2
Baso-0.7
___ 06:00AM BLOOD ___ PTT-30.2 ___
___ 01:40PM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-140
K-4.4 Cl-105 HCO3-22 AnGap-17
___ 06:00AM BLOOD ALT-25 AST-20 LD(LDH)-123 CK(CPK)-53
AlkPhos-80 TotBili-0.7
___ 06:00AM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.2 Mg-2.2
___ 06:00AM BLOOD TSH-1.7
___ 01:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CXR: No acute cardiopulmonary process.
EKG: Sinus rhythm with non-specific repolarization
abnormalities. No previous tracing available for comparison.
EEG:
This continuous video monitoring study captured two episodes of
unresponsiveness preceded by typical presyncopal symptoms of
palpitations, lightheadedness, tunnel vision, and difficulty
speaking followed by loss of consciousness. Both of these events
occurred while she was sitting and trying to get up from the
commode. The EEG during these two episodes showed an alpha
rhythm consistent with a normal waking background, and there was
no
electrographic evidence of seizures. However, the single channel
EKG
demonstrated significant sinus arrhythmia with large heart rate
variations ranging between 66 bpm to 144 bpm. There were no
clear epileptiform discharges or electrographic seizures.
Additionally, prominent sinus arrhythmia could be seen at other
times during wakefulness, at rest, with heart rates ranging
between 60-120 bpm. These findings raise concern for a primary
cardiac rhythm abnormality.
MRI BRAIN with thin cuts through brainstem:
1. There is no evidence of acute intraparenchymal pathology.
2. Incidentally noted is a T1 hypo-, T2 hyper-intense
nonenhancing lesion arising from the dorsal clivus and extending
exophytically into the prepontine cistern which may represent an
ecchordosis physaliphora at the dorsal wall of the clivus. This
may be further evaluated with a sagittal CISS sequence and thin
axial pre and post gad images and a CT of the skull base.
Medications on Admission:
- metoprolol 25mg BID
- mestinon 30mg QID
- fludrocortisone 0.2mg QHS
- topamax 10mg QD
- klonipin 0.5mg QHS
- amitriptyline 20mg QD
- estradiol 1 mg daily
Discharge Medications:
1. Nadolol 40 mg PO DAILY
hold if HR<60 or sBP<100
RX *nadolol 40 mg 1 (One) Tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*2
2. Estradiol 1 mg PO DAILY
RX *estradiol 1 mg 1 (One) Tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
3. Citalopram 10 mg PO DAILY
Please stop taking if develope shortness of breath or hives
RX *Celexa 10 mg 1 (One) Tablet(s) by mouth once a day Disp #*30
Tablet Refills:*6
4. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
inappropriate sinus tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam normal except decreased sensation to temp and pin in
gradient at distal lower extremities
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female with syncope.
FINDINGS: PA and lateral views of the chest. No prior. The lungs are clear.
There is no effusion or pneumothorax. Cardiomediastinal silhouette is normal.
Osseous and soft tissue structures are unremarkable. Surgical clips in the
right upper quadrant suggest prior cholecystectomy.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ woman with intermittent tachycardia and posturally
mediated episodes of unresponsiveness.
COMPARISON: None.
TECHNIQUE: MRI of the head was obtained with and without contrast. Sagittal
T1, axial T1, axial T2 star GRE, axial FLAIR, axial T2 images were obtained
without the administration of contrast. Following the administration of
contrast, axial T1 and sagittal MP-RAGE images were obtained.
Diffusion-weighted and ADC maps were also generated and reviewed.
FINDINGS: No evidence of acute intracranial hemorrhage, brain edema, mass
effect, or shift of normally midline structures. The ventricles and sulci are
normal in size and configuration. There is no diffusion abnormality. There
is no evidence of acute major vascular territory infarction. A FLAIR
hyperintensity within the left periventricular white matter (series 7, image
15) is nonspecific.
A T1 hypointense, T2 hyperintense nonenhancing lesion arising from the dorsal
wall of the clivus and extending exophytically into the prepontine cyst
(series 9, image 121) may represent ecchordosis physaliphora at the dorsal
wall of the clivus.
Bilateral mastoid air cells and visualized paranasal sinuses are clear. The
orbits and conus are symmetric.
IMPRESSION:
1. There is no evidence of acute intraparenchymal pathology.
2. Incidentally noted is a T1 hypo-, T2 hyper-intense nonenhancing lesion
arising from the dorsal clivus and extending exophytically into the prepontine
cistern which may represent an ecchordosis physaliphora at the dorsal wall of
the clivus. This may be further evaluated with a sagittal CISS sequence and
thin axial pre and post gad images and a CT of the skull base.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LOC
Diagnosed with SYNCOPE AND COLLAPSE, CARDIAC DYSRHYTHMIAS NEC
temperature: 98.8
heartrate: 92.0
resprate: 16.0
o2sat: 100.0
sbp: 157.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | NEURO:
Ms. ___ was admitted to Neurology Service after having an
event of unresponsiveness during tilt table testing that was
concerning for seizure. She monitored on continuous video EEG
for 48 hours. Several of her medications (amitriptyline,
florinef, mestinon, metoprolol) were stopped in order to better
evaluate her baseline function and capture events. She did have
3 typical events in the first 24 hours of admission. These
occurred while on the commode, and began with the usual
tachycardia and palpitations, followed by rising tingling
sensation up the neck and shortness of breath, slowly losing the
ability voice though at first able to understand, then no longer
able to speak or understand, and finally LOC. She would remain
unresponsive to sternal rub or nailbed pressure, despite normal
blood pressure, after she had been laid supine, and this would
persist for 5 minutes. After this she would awaken and appear
back to baseline, no post-ictal period. EEG was normal during
all of these events. However, EKG leads of the EEG did capture
intermittently elevated heart rate to 140-160s alternating with
normal rate during the episodes.
Autonomics was consulted in order to rule out primary
dysautonomia. The autonomics testing done just prior to
admission had revealed only inappropriate tachycardia, with no
other evidence of systemic primary dysautonomia and stable BP
during her testing and event. THe autonomics team recommded MRI
brain with thin cuts through brainstem, this showed
They also recommended urine catecholamines and 5-HIAA which were
pending at the time of discharge. She will follow up with
autonomics division in 2 weeks.
She does not need to restart mestinon/florinef/etc, because she
does not have orthostatic hypotension (only tachycardia).
Topamax was also stopped because of concern for worsening her
symptoms, and also it was ineffective for migraine prophylaxis
for her. SHe was started on nadolol as recommended by cardiology
(see below) and we will also try this for migraine ppx. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___ THORACENTESIS
History of Present Illness:
___ F with a history of atrial fib on ___ with recent
fall resulting in ___ in ___ complicated by rib fractures
and right sided pleural effusion that required drainage presents
with recurrent effusion and SOB.
In terms of her pleural effusion, her daughter reports that it
was first discovered by the patients cardiologist after Ms.
___ was complaining of shortness of breath. A CXR was done
for further evaluation which revealed a pleural effusion. The
pleural effusion, however, is noted on prior CXRs from ___ (unavaible in our system, only per reports in radiology
reports). She was going to be evaluated by IP but then she
suffered a ___ and her pleural effusion was managed as an
inpatient (see below).
She was last hospitalizated from ___ where she had a ___
and also underwent drainage of the known pleural effusion. She
had an uncomplicated removal of 2.5 liters of exudative effusion
(Tprot pleural fluid/Tprot serum >0.5). CT chest after drainage
showed
trapped lung with residual pneumothorax but no effusion. She was
going to follow-up with IP as an outpatient for further
management of her pleural effusion. The pleural effusion was
thought to be secondary to trauma from rib fractures related to
her fall.
She presents from ___ today for increasing SOB. Her
SOB was intermittent after her time post-discharge. She noted
that it was worse when it was going to rain. She went her PCP on
___ for a follow-up visit where a CXR showed reaccumulation
of right effusion. She became increasingly SOB with exertion the
day prior to admission and SOB worse with lying flat so she went
for evaluation at ___. She also described wheezing and
cough. She was then transferred to ___ for further management.
In the ED, initial vitals were:
97.8 85 170/111 18 98%
Labs in the ED notable for WBC 4.9, Hg 12.1, Plts 106. Chem 7
with sodium 141, potassium 4.1, Cl 104, BUN 24, BUN 16, Cr 1.0,
INR 1.3.
On the floor, she reports feeling comfortable in bed in terms of
her respiratory status. She does have a headache.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
- traumatic small right-sided SDH and left parietal SAH
- atrial fibrillation (off coumadin since ___
- silent L cerebellar CVA (seen on imaging, patient denies this)
- hypertension
- hyperlipidemia
- osteoarthritis
- L knee replacement
- R hip replacement
Social History:
___
Family History:
Mother - CVA in her ___
Father - MI in his ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 ___ 94%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds over the right lung, CTA on the
left
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: WWP, no edema
Neuro: CN II-XII intact
DISCHARGE PHYSICAL EXAM:
Vitals: T: 97.9 BP:114/87 P:86 RR:18 O2stat:98%RA
General: Alert, oriented, anxious, normal speech.
HEENT: No JVD, no LAD
Lungs: Right lung with crackles and diminished aeration at base,
but much improved from ___. Left lung with crackles at the
base.
CV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes or lesions
Neuro: Alert & oriented, no focal neuro deficit, no facial
assymetry,
MSK: On hands bilaterally, there is ulnar deviation of the
digits. No ulnar deviation at the wrists. ___ nodes;
rare Heberdon's nodes. Hallux abducto valgus deformity of the
feet bilaterally.
Skin: No rash
Pertinent Results:
ADMISSION LABS:
___ 06:40PM GLUCOSE-106* UREA N-16 CREAT-1.0 SODIUM-141
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-24 ANION GAP-17
___ 06:40PM estGFR-Using this
___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8*
BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34
AbsEos-0.57* AbsBaso-0.06
___ 06:40PM NEUTS-56.5 ___ MONOS-7.0 EOS-11.8*
BASOS-1.2* IM ___ AbsNeut-2.74 AbsLymp-1.11* AbsMono-0.34
AbsEos-0.57* AbsBaso-0.06
___ 06:40PM PLT COUNT-279
___ 06:40PM ___ PTT-32.3 ___
___ 04:35PM URINE HOURS-RANDOM
___ 04:35PM URINE HOURS-RANDOM
___ 04:35PM URINE UHOLD-HOLD
___ 04:35PM URINE GR HOLD-HOLD
___ 04:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
PERTINENT RESULTS: PLEURAL FLUID STUDIES
___ 12:40PM PLEURAL WBC-460* RBC-1090* Polys-0 Lymphs-11*
Monos-2* Eos-86* NRBC-2* Macro-1*
___ 12:40PM PLEURAL Hct,Fl-UNABLE TO
___ 12:40PM PLEURAL TotProt-3.1 Glucose-122 Creat-0.9
LD(LDH)-132 Amylase-27 Albumin-2.0 Cholest-51
___ 12:40PM PLEURAL Misc-PRO BNP =
DISCHARGE LABS:
___ 07:07AM BLOOD WBC-5.8 RBC-3.53* Hgb-11.9 Hct-37.1
MCV-105* MCH-33.7* MCHC-32.1 RDW-14.0 RDWSD-53.3* Plt ___
___ 07:07AM BLOOD Plt ___
___ 07:07AM BLOOD Glucose-98 UreaN-18 Creat-1.1 Na-138
K-3.9 Cl-102 HCO3-24 AnGap-16
IMAGING:
___ CXR FROM ___ HOSP: large right sided pleural
effusion
___ CXR In comparison with the study of ___, there is
little change in the pleural
effusion extending upward to the midportion of the right lung
with associated
volume loss in the right lower and possibly right middle lobe.
The left lung
is essentially clear and there is no evidence of vascular
congestion.
___ CXR Right pleural effusion is resolved. No pneumothorax
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 25 mg PO BID
2. Apixaban 2.5 mg PO BID
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
4. Vitamin B Complex 1 CAP PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
2. Carvedilol 25 mg PO BID
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
4. Vitamin B Complex 1 CAP PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
7. LaMOTrigine 50 mg PO QHS
RX *lamotrigine 100 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
RX *lamotrigine 100 mg ___ tablet(s) by mouth twice/day Disp
#*60 Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Pleural effusion
2. Possible partial temporal lobe seizures.
SECONDARY DIAGNOSES:
1. Hypertension
2. Atrial fibrillation
3. Arthritis
4. H/o ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with known effusion // eval for any interval
change in pleural effusion eval for any interval change in pleural
effusion
IMPRESSION:
In comparison with the study of ___, there is little change in the pleural
effusion extending upward to the midportion of the right lung with associated
volume loss in the right lower and possibly right middle lobe. The left lung
is essentially clear and there is no evidence of vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pleural effusion, now with increased SOB,
sat's stable at 98 on 2L, please eval for growing effusion // please eval for
growing effusion please eval for growing effusion
COMPARISON: Prior chest radiographs ___.
IMPRESSION:
Moderate to large right pleural effusion is unchanged. No pneumothorax.
Right lung base is obscured and substantially atelectatic. Apparent increase
in cardiac silhouette size is due in part to adjacent pleural effusion. Left
lung clear. Heart size normal.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with ___ year old woman on heparin drip, hx of
sdh/sah, nwo with word finding difficulties, concern for tia vs stroke. //
any head bleed or evidence of acute stroke?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 5.6 s, 14.6 cm; CTDIvol = 53.8 mGy (Head) DLP =
785.0 mGy-cm.
Total DLP (Head) = 785 mGy-cm.
COMPARISON: ___ noncontrast CT head.
FINDINGS:
There is no evidence of major vascular territory infarction, new intracranial
hemorrhage, edema, or mass. The ventricles and sulci are mildly prominent,
suggestive of age-related involutional changes. Scattered periventricular
white-matter hypodensities are present, consistent with chronic small vessel
ischemic disease. There is evidence of mild encephalomalacia in the left
posterior occipital, unchanged from prior imaging.
No osseous abnormalities are seen. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of new hemorrhage.
Radiology Report
INDICATION: ___ year old woman with right pleural effusion s/p thoracentesis.
// assess for PTX or other complication of thoracentesis
EXAMINATION: CHEST (PORTABLE AP)
TECHNIQUE: Portable chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Previously seen large right pleural effusion is now resolved. There is no
consolidation or pneumothorax. Cardiomediastinal silhouette is normal size.
Tortuous aortic contour is stable.
IMPRESSION:
Right pleural effusion is resolved. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion
Diagnosed with PLEURAL EFFUSION NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 97.8
heartrate: 85.0
resprate: 18.0
o2sat: 98.0
sbp: 170.0
dbp: 111.0
level of pain: 0
level of acuity: 2.0 | In brief this is a ___ yr old female who has a hx of Afib on
Apixaban, hypertension, recent admission for fall w/ traumatic
SDH & SAH, recent admission for a ___ complicated by rib
fractures and right sided hemorrhagic pleural effusion, now
presenting with SOB and found to have recurrent right pleural
effusion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Clindamycin / Cephalosporins
Attending: ___.
Chief Complaint:
Right third toe pain
Major Surgical or Invasive Procedure:
Right third toe amputation (___)
History of Present Illness:
FROM ADMISSION NOTE:
Ms. ___ is an ___ y/o woman with type II diabetes,
hypertension, hypercholestermia, and diabetic neuropathy and
recurrent cellulitis with a past history of DVT and PE,
presenting with right toe pain.
Ms. ___ has a history of chronic leg and foot pain. About
two
weeks ago, she noted worsened pain in her right toes. Her
daughter noticed that there was blood on the patient's sock.
Subsequently, the patient's daughter noticed that her toes were
frequently bleeding and had a new foul odor. Her daughter tried
to treat the foot with athlete's foot spray and foot powder, but
there was no improvement in symptoms. The pain continued to
worsen over the week reaching ___ pain. Due the pain, it was
difficult for the patient's daughter to closely examine the foot
but she did note that the skin was broken down between the
second
and third toe on the right foot. The pain was localized to the
toe and did not radiate. The patient denies any fevers, chills,
nausea, or vomiting. Due to worsening pain the patient went to
her podiatrist. She had radiographs taken of her foot which were
suggestive of osteomyelitis, and the physician recommended
admission to ___ for possible surgery.
She has a history of cellulitis and was admitted to ___ in ___ for IV Vanc after failing doxycycline as an
outpatient.
Separately, Ms. ___ noted that she had bilateral lower
extremity swelling for the past three weeks, with left>right
extending from the knee to the toes. ___ at the OSH was
negative
for LLE DVT. She has a history of DVT in her leg with subsequent
PE in her ___, for which she is on life long anticoagulation
with
warfarin. She denies miscarriages, a family history of
clotting,
although her mother died in her ___ or ___s from a stroke. She
denies having been on any estrogen containing medications at the
time of her DVT/PE.
Her primary care doctor ordered ___ chest ___ which revealed
"mild vascular redistribution consistent with mild CHF"
She was started on 20 furosemide PO. The right lower extremity
swelling improved but the left lower extremity swelling only
improved minimally. Her PCP increased the dose to 40mg daily.
She has a long standing history of "heart murmur," but denies
any
other problems with her heart. She remembers getting a stress
test about ___ years ago, and a cardiac echo ___ years ago. She
denies lightheadedness, vision changes, SOB, and chest pain.
She
sleeps sitting up, but this may be related to dizziness more
that
orthopnea.
Per Dr ___ DPM podiatry note ___ --------------
DM, neuropathy right lower leg with worsening pain.
Pt has been wearing surgical shoe because any pressure on the
skin is painful.Right ___ digit medial aspect full thickness
ulceration. Radiographs today: from my view, there is erosive
changes of the proximal phalanx head medially with dislocation
of
the middle and distal phalanx laterally.
I reviewed radiographs with her daughter and discussed
seriousness of this condition. She will most likely need a toe
amputation due to amount of bone destruction.
I recommended that she take her to the ER at ___ for evaluation,
admission and likely surgery.
She will discuss this with her mother and will either take her
today or tomorrow. If she does take her tomorrow, I recommended
that she apply betadine soaked gauze in between the toes. I
provided her with supplies.
Pt's daughter understands the seriousness of this condition. If
she delays much longer, infection can worsen and she may become
septic.
See note form her podiatry visit today And xray with likely
osteomyelitis of her rt ___ toe
In the ED, initial vitals: Temp 99.7 F HR 73 148/73 RR 20 100%
RA
- Exam notable for:
A&Ox3
- Labs notable for:
WBC 5.4 hgb 10.0 MCV 83 plt 258
___ 1.4 PTT 29
Na+ 142 K+ 4.7 BUN 15 Cr 0.7
BCx 2X,
- Imaging notable for:
XRAY ___ Atrius
Bone loss at the distal end of proximal phalanx with PIP
dislocation as above.
Osteomyelitis suspected.
LENIs ___
Limited study due to severe soft tissue swelling at the left
calf, obscuring visualization of the posterior tibial and
peroneal veins. No deep vein thrombosis is identified in the
remaining deep venous system in the left leg.
MRI ___
IMPRESSION:
Bilateral lower lower leg subcutaneous edema and perifascial
edema, left worse than right.
- Pt given:
Vancomycin 1 g
Flagyl 500 mg
Cipro 400 mg
- Vitals prior to transfer: Temp 99 HR 76 134/62 RR 18 99% RA
On the floor, she reports feeling about the same, with now
minimal pain in her R toe. Her daughter was present and able to
account for her medications.
Past Medical History:
FROM ADMISSION NOTE:
DM (diabetes mellitus), type 2
Recurrent DVTs with PE
Recurrent Cellulitis
Thrombophlebitis/phlebitis
Hypertension, essential
HLD
Recurrent UTIs
Pelvic floor dysfunction, uterine prolapse, has pessary
Osteoarthritis
h/o Breast Cancer - DCIS
Ocular hypertention, cataracts, CME (cystoid macular edema)
Hematuria
Anemia
Osteoarthritis
Positive PPD
Social History:
___
Family History:
FROM ADMISSION NOTE:
mother had stroke and died in her ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITALS: T98.4 BP144/75 HR73 RR18 ___ 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM
CV: Regular rate and rhythm, normal S1 + S2, ___ ejection
murmur
LUSB, no rubs or gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, no organomegaly, no
rebound or guarding, well healed V incision below umbilicus,
nystatin powder under pannus
GU: No foley
Ext: Warm, well perfused, 1+ pitting edema from to tibial
tuberosity, no clubbing, cyanosis, purulent ulcer about 1cm in
diameter on medial surface of the third toe and the lateral
surface of the second toe, maceration between all toes ___.
Chronic venous stasis changes, woody skin texture to mid tibia.
R>L foot swelling.
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: T 98.4, HR 71, BP 149/82, RR 16, O2 98% RA
GENERAL: NAD, sitting upright in chair
HEENT: PERRL, EOMI, MMM, conjunctival pallor, no sublingual
pallor
NECK: supple, no LAD
CV: RRR, III/VI systolic crescendo-decrescendo murmur heard best
at RUSB, radiation to neck, S1/S2, no rubs or gallops
RESP: unlabored, CTAB
GI: soft, non-distended, non-tender, normoactive BS
GU: no suprapubic tenderness, no Foley
MSK: right foot bandage c/d/i, atrophic, discolored nails, 1+
pitting edema to mid-shin bilaterally, chronic venous stasis
dermatitis
SKIN: no erythema
NEURO: non-focal
Pertinent Results:
ADMISSION LABS:
===============
___ 11:23AM BLOOD WBC-5.4 RBC-3.98 Hgb-10.0* Hct-32.9*
MCV-83 MCH-25.1* MCHC-30.4* RDW-14.8 RDWSD-44.2 Plt ___
___ 11:23AM BLOOD Neuts-55.1 ___ Monos-11.7
Eos-0.9* Baso-0.6 Im ___ AbsNeut-2.96 AbsLymp-1.67
AbsMono-0.63 AbsEos-0.05 AbsBaso-0.03
___ 11:23AM BLOOD ___ PTT-29.2 ___
___ 11:23AM BLOOD Glucose-106* UreaN-15 Creat-0.7 Na-142
K-4.7 Cl-104 HCO3-24 AnGap-14
___ 11:23AM BLOOD ALT-11 AST-23 LD(LDH)-192 AlkPhos-84
TotBili-0.2
___ 11:23AM BLOOD Albumin-3.7
___ 12:27AM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 12:27AM URINE Blood-SM* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-LG
___ 12:27AM URINE RBC-88* WBC->182* Bacteri-NONE Yeast-NONE
Epi-2
___ 06:20AM BLOOD SED RATE-87
DSICHARGE LABS:
==============
___ 05:39AM BLOOD WBC-4.4 RBC-3.58* Hgb-9.3* Hct-29.5*
MCV-82 MCH-26.0 MCHC-31.5* RDW-15.4 RDWSD-45.3 Plt ___
___ 05:39AM BLOOD ___
___ 05:39AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-141
K-4.0 Cl-105 HCO3-24 AnGap-12
RADIOLOGY:
=========
FOOT AP,LAT & OBL RIGHT PORT (___)
IMPRESSION:
Proximal phalanx of the right third toe has been partially
resected,, at a
level 12 mm from the proximal interphalangeal joint. There is
no subcutaneous
emphysema. No other changes since preoperative foot radiograph
on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain - Severe
2. Oxymorphone HCl 30 mg po BID
3. Nystatin Ointment 1 Appl TP TID:PRN itchy
4. Furosemide 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Amitriptyline 25 mg PO QHS
7. OXcarbazepine 300 mg PO MORNING AND NOON
8. OXcarbazepine 150 mg PO QHS
9. Nitrofurantoin (Macrodantin) 50 mg PO QHS chronic recc uti
10. Warfarin 5 mg PO 4X/WEEK (___)
11. Warfarin 3.75 mg PO 3X/WEEK (___)
12. trospium 20 mg oral DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*70 Tablet Refills:*0
3. Docusate Sodium 100 mg PO DAILY constipation
4. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*105 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 1000 mg IV q12hrs Disp #*140 Vial
Refills:*0
8. Warfarin 2.5 mg PO DAILY16
9. Amitriptyline 25 mg PO QHS
10. Furosemide 20 mg PO DAILY
11. Nystatin Ointment 1 Appl TP TID:PRN itchy
12. OXcarbazepine 300 mg PO MORNING AND NOON
13. OXcarbazepine 150 mg PO QHS
14. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Severe
15. Oxymorphone HCl 30 mg po BID
16. Simvastatin 20 mg PO QPM
17. trospium 20 mg oral DAILY
18. HELD- Nitrofurantoin (Macrodantin) 50 mg PO QHS chronic recc
uti This medication was held. Do not restart Nitrofurantoin
(Macrodantin) until you see your primary care and you are done
with your antibiotic medication for your toe
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ female with right foot wound here for evaluation of
osteomyelitis.
TECHNIQUE: Three views of the right foot.
COMPARISON: None available.
FINDINGS:
Osteolysis along the medial aspect of distal portion of the proximal phalanx
of the third toe with soft tissue swelling is concerning for osteomyelitis.
The third toe is dislocated at the PIP joint with the middle phalanx laterally
dislocated relative to the proximal phalanx. There is no acute fracture.
Moderate degenerative changes are seen at the first MTP joint, PIP joints the
___ to ___ digits, and midfoot. There is a small calcaneal spur. There is
diffuse demineralization. No subcutaneous emphysema.
IMPRESSION:
1. Osteolysis along the medial aspect of the distal portion of the proximal
phalanx of the third toe with soft tissue swelling, concerning for
osteomyelitis.
2. Dislocated third toe at the PIP joint.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ female presenting with left leg swelling here for
evaluation of DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Lower extremity ultrasound dated ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins.
The posterior tibial and peroneal veins are not visualized due to severe soft
tissue swelling.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Limited study due to severe soft tissue swelling at the left calf, obscuring
visualization of the posterior tibial and peroneal veins. No deep vein
thrombosis is identified in the remaining deep venous system in the left lower
extremity.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old woman s/p r third toe amputation// eval post op
eval post op
IMPRESSION:
Proximal phalanx of the right third toe has been partially resected,, at a
level 12 mm from the proximal interphalangeal joint. There is no subcutaneous
emphysema. No other changes since preoperative foot radiograph on ___.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman with picc// r picc 50cm iv ___ ___ Contact
name: ___: ___
TECHNIQUE: Single portable upright frontal chest radiograph.
COMPARISON: None.
FINDINGS:
Limited evaluation due to patient rotation. A right PICC tip terminates in
the right atrium. The lungs are moderately well inflated. Right lower lobe
atelectasis noted. Trace left pleural effusion noted. No right pleural
effusion. No pneumothorax.
IMPRESSION:
1. Right PICC tip in right atrium. Considering withdrawing 1.5 cm for better
positioning.
2. Right lower lobe atelectasis.
3. Trace left pleural effusion.
NOTIFICATION: The findings were discussed with ___, IV nurse by ___
___, M.D. on the telephone on ___ at 6:04 pm, 1 minutes after
discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Foot pain
Diagnosed with Type 2 diabetes mellitus with other specified complication, Other acute osteomyelitis, right ankle and foot
temperature: 99.7
heartrate: 73.0
resprate: 20.0
o2sat: 100.0
sbp: 148.0
dbp: 73.0
level of pain: 8
level of acuity: 3.0 | ___ female with history of DM2, remote DVT/PE, on
lifetime AC, admitted for subacute cellulitis/osteomyelitis of
right third toe s/p uncomplicated amputation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilaudid
Attending: ___.
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
NGT
History of Present Illness:
___ M with advanced metastatic
intraperitoneal mucinous adenocarcinoma of presumed appendiceal
primary presents with worsening of abdominal pain, nausea,
vomiting.
Per review of records, initially presented for care in ___ in ___. At that point, she was having
abdominal
pain, diarrhea, bloating, decreased appetite, early satiety, and
a 25-pound weight loss over the preceding few months. She
underwent a CT scan, which showed a right adnexal hypodense
lesion. A pelvic ultrasound showed a multiseptated cystic lesion
without vascularization. On ___, she underwent an
exploratory laparotomy and drainage of 20 mL of ascites that
showed malignancy on pathology. There was a biopsy of a right
ovarian mass, which showed inflammation but no evidence of
malignancy. A biopsy of an omental mass was positive for
metastatic adenocarcinoma. She had elevated CEA and CA-125. She
subsequently moved to the ___ area where she presented for
care. An omental biopsy on ___, showed metastatic
mucinous adenocarcinoma. The differential diagnosis included a
GI
or appendiceal primary, pancreaticobiliary, ovarian, or
uterine/cervical primary. She underwent a thorough GI
evaluation,
which was negative. She was started on neoadjuvant chemotherapy
with carboplatin and paclitaxel with the assumption that this
represented a gynecologic malignancy.
The patient was last seen at ___ ___ for similar
symptoms,
s/p chemo most recently last year with carbotaxol but did not
elect to pursue further chemotherapy if intent was purely
palliative. Underwent ex-lap in ___ for planned
surgical
debulking, extensive tumor burden at that time resulted in
failure of debulking procedure, pt was advised to pursue HIPEC
at
___, unclear if she established care. She did elect to return
to ___ to spend time with family; developed worsening
abdominal distension approximately 3 weeks ago with some serous
leakage of fluid around her umbilicus. This was managed with an
ostomy appliance, has not noted any drainage for past 4 days.
Now
having worsening abd pain, nausea, vomiting, and inability to
tolerate PO. Last BM 4 days ago, underwent CT scan in ED that
showed concern for mass effect from tumor on small bowel.
In the ED, initial vitals were: 97.6 82 106/67 16 100% RA. Exam
notable for cachectic woman, with distended abdomen, hypoactive
bowel sounds, with ostomy in place without output in the bag,
severe tenderness to light palpation, with diffuse guarding.
Labs
showed WBV of 11.8, H/H of 11.7/37.3, Plt 645. BMP notable for
Na
of 131, K 3.9, Cl 95, HCO3 23, BUN 11, Cr of 0.6. LFTS
unremarkable with an alk phos of 150. Lactate 1.2. Imaging
showed
marked progression of primary and metastatic tumor burden.
Received 2 mg IV morphine and was started on LR. ACS was
consulted and recommended NG tube decompression. Decision was
made to admit to medicine for further management.
On the floor, patient reports the history above and c/o
abdominal
pain.
Review of systems: 10-point ROS was performed and is negative
except as noted in the HPI.
Past Medical History:
PMH:
- Asthma
- Osteoporosis
- Denies hypertension, diabetes, thromboembolic disease
PSH:
- Abdominal surgery to remove her placenta post-partum (pt
unclear re details, occurred after vaginal delivery, via small
infraumbilical 4cm vertical incision)
- Ex lap, drainage of ascites, omental bx, peritoneal bx,
ovarian
bx, ___, ___
___:
- ___ (4 deceased in neonatal period)
- SVD x 11
- One pregnancy c/b ? retained placenta, requiring abdominal
surgery via vertical 4cm infraumbilical incision
PGYN:
- Menopausal, late ___
- Denies postmenopausal bleeding
- Not currently sexually active
- Denies hormonal replacement therapy or history of OCPs
- Never had a Pap smear (pt denies and nothing in CHA records
since ___
- Denies history of pelvic infections or sexually transmitted
infections
- Denies history of fibroids or cysts
Social History:
___
Family History:
- Sister died of liver cancer
- No known family history of breast, uterine, ovarian, cervical
or colon cancer
- No known history of bleeding or clotting disorder
Physical Exam:
UPON ADMISSION:
Vital Signs: 98.7 PO 94 / 60 79 16 95 RA
General: ___ woman crying, in moderate distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, decreased breath
sounds
at the bases bilaterally
Abdomen: moderately distended, TTP, focal guarding in the LUQ,
+rebound tenderness
GU: No foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
UPON DISCHARGE:
VS: 98.2 100 / 56 80 16 95% ra
General: ___ female, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRLA
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, decreased breath
sounds at the bases bilaterally
Abdomen: moderately distended, TTP, focal guarding in the LLQ,
+rebound tenderness, area of localized hyperpigmented skin
overlying umbilicus with no drainage
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS UPON ADMISSION:
___ 10:05PM BLOOD WBC-11.8* RBC-4.63 Hgb-11.7 Hct-37.3
MCV-81* MCH-25.3* MCHC-31.4* RDW-15.1 RDWSD-43.9 Plt ___
___ 10:05PM BLOOD Glucose-113* UreaN-11 Creat-0.6 Na-131*
K-3.9 Cl-95* HCO3-23 AnGap-17
___ 10:05PM BLOOD ALT-11 AST-20 AlkPhos-150* TotBili-0.4
___ 10:05PM BLOOD Albumin-2.9*
LABS UPON DISCHARGE
___ 08:00AM BLOOD WBC-9.6 RBC-3.74* Hgb-9.4* Hct-30.4*
MCV-81* MCH-25.1* MCHC-30.9* RDW-15.3 RDWSD-44.8 Plt ___
___ 08:00AM BLOOD Glucose-78 UreaN-4* Creat-0.4 Na-136
K-3.8 Cl-101 HCO3-26 AnGap-13
___ 07:50AM BLOOD ALT-6 AST-12 AlkPhos-103 TotBili-0.3
___ 08:00AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.5*
EKG on admission:
Sinus rhythm. There is an early transition that is non-specific.
Low voltage in the precordial leads. Non-specific ST-T wave
changes. The Q-T interval is prolonged. Compared to the previous
tracing of ___ these findings are new.
CT abdomen and pelvis w/contrast:
IMPRESSION:
1. Markedly increased primary and metastatic tumor burden.
Metastatic
deposits extend through the anterior wall defect into the
"ostomy".
2. Distention of proximal loops of small bowel with relative
decompression but node discrete transition point in the distal
ileum, compatible with partial obstruction likely due to mass
effect by the large intra-abdominal cystic mass.
Abdominal KUB:
IMPRESSION:
No intraperitoneal free air. Normal bowel gas pattern.
CXR:
IMPRESSION:
In comparison with the study of ___, there are
lower lung
volumes. No evidence of vascular congestion or acute focal
pneumonia.
There has been placement of a nasogastric tube that extends to
the lower body of the stomach. Residual contrast material is
seen in the colon.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour Place on skin every three days Disp #*3
Patch Refills:*0
2. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Disp #*170 Gram Refills:*0
ALSO DISCHARGED WITH PRESCRIPTIONS FOR:
"Hospice comfort kit contents"- acetaminophen 650 suppository,
atropine 1% oral drops, bisacodyl 10 mg suppository, haloperidol
5 mg/1 ml oral solution, lorazepam 5 mg/1ml oral solution,
senna-s
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Metastatic intraperitoneal mucinous adenocarcinoma
Partial small bowel obstruction
Hypotension
Thrombocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: +PO contrast; History: ___ with ostomy, abdominal pain, vomiting,
no ostomy output+PO contrast // eval for obstruction
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 5.0 s, 55.0 cm; CTDIvol = 11.7 mGy (Body) DLP = 643.0
mGy-cm.
Total DLP (Body) = 650 mGy-cm.
COMPARISON: CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: There is dependent atelectasis in the visualized lung bases. No
pleural or pericardial effusion is seen.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in background attenuation, without
focal lesion or intra or extrahepatic biliary duct dilation. The contour is
lobulated secondary to pseudomyxoma peritonei. The main portal vein appears
patent. The gallbladder is within normal limits.
PANCREAS: Pancreas is atrophic but normal in attenuation without mass, ductal
dilation, or peripancreatic stranding or fluid collection.
SPLEEN: Spleen is normal in size. Several cystic lesions are again seen,
similar in appearance and distribution compared to ___.
ADRENALS: The adrenal glands are normal in caliber and configuration
bilaterally.
URINARY: The kidneys are symmetric and normal in size. There is an unchanged
hypodensity arising from the interpolar region of the right kidney, possibly a
cyst. There is no hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops are
distended with contrast proximally, with relative decompression at the level
of the distal ileum likely due to mass effect from the cystic mass. There is
no discrete transition point. The colon and rectum are within normal limits.
The large cystic mass which appears to originate in the right lower quadrant,
presumably the suspected appendiceal mucinous carcinoma, has increased in
size, now measuring 13.6 x 19.6 x 24.3 cm (previously 11.5 x 18.1 x 13.9 cm).
There are increased omental deposits and omental caking. Mucinous material
throughout the abdomen is increased and again compatible with pseudomyxoma
peritonei. This material also extends through an anterior abdominal wall
defect, presumably into the "ostomy" . There may also be a component of
ascites, but is difficult to differentiate from the mucinous deposits
throughout the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is an anterior wall defect as described above, without
evidence of enterostomy or colostomy. Peritoneal wall deposits extend through
the defect. Additional low density lesions in the subcutaneous tissues of the
right anterior abdominal wall are likely additional metastatic implants.
IMPRESSION:
1. Markedly increased primary and metastatic tumor burden. Metastatic
deposits extend through the anterior wall defect into the "ostomy".
2. Distention of proximal loops of small bowel with relative decompression but
node discrete transition point in the distal ileum, compatible with partial
obstruction likely due to mass effect by the large intra-abdominal cystic
mass.
Radiology Report
INDICATION: ___ year old woman with partial SBO, diffusely guaerding and
peritontic // eval for free air
TECHNIQUE: Supine and left lateral decubitus abdominal radiographs were
obtained.
COMPARISON: CT abdomen pelvis dated ___ at 02:50.
FINDINGS:
Contrast material is seen in the ascending and transverse colon and bladder
consistent with recent CT abdomen and pelvis performed earlier on the same
day. There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative disease of the lumbar spine.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No intraperitoneal free air. Normal bowel gas pattern.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old woman with NGT placement for SBO eval position //
eval ngt eval ngt
IMPRESSION:
In comparison with the study of ___, there are lower lung
volumes. No evidence of vascular congestion or acute focal pneumonia.
There has been placement of a nasogastric tube that extends to the lower body
of the stomach.
Residual contrast material is seen in the colon.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Unspecified intestinal obstruction
temperature: 97.6
heartrate: 82.0
resprate: 16.0
o2sat: 100.0
sbp: 106.0
dbp: 67.0
level of pain: 8
level of acuity: 2.0 | ___ with metastatic intraperitoneal mucinous adenocarcinoma of
presumed appendiceal primary not currently receiving treatment
who presented with abdominal pain, abdominal distension, emesis
found to have partial small bowel obstruction.
Patient had CT scan upon admission that showed increased primary
and metastatic tumor burden as well as a partial bowel
obstruction. Surgery was consulted and recommended no surgical
intervention. NGT was placed to intermittent suction with
minimal output. NGT placed to gravity and pt had nausea and
abdominal pain. NGT was then placed back on to suction with
relief of symptoms. NGT was to gravity prior to discharge and
patient's pain was stable.
Imaging noteable for worsening of patient's malignancy. Pt has
been out of the country (___) for nearly a year and has
received some medical treatment there (antibiotics per her
family). Patient reported that she would not want chemotherapy
or surgery. Palliative care was consulted and met with the
patient. After an extensive goals of care discussion, pt was
made DNR/DNI and is going home with hospice services.
**TRANSITIONAL ISSUES**
-Patient was discharged with "Hospice comfort kit contents"-
acetaminophen 650 suppository, atropine 1% oral drops, bisacodyl
10 mg suppository, haloperidol 5 mg/1 ml oral solution,
lorazepam 5 mg/1ml oral solution, senna-s
-Also wrote script for fentanyl patch if needed
-Please maintain patient's comfort
-MOLST form was signed on ___. DNR/DNI, do not hospitalize |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Exelon / Aricept / Penicillins
Attending: ___.
Chief Complaint:
Ground level fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year old female with dementia who
presents today after an unwitnessed fall in her assisted living
facility ___.) The patient is unable to provide a
history and does not participate completely with physical
examination.
In the ___ ED, initial vitals were T 99.0 BP 138/70 RR 14 SpO2
98% on RA. ED exam notable for abrasions on the R UE and L UE
and A&Ox1.
- Initial labs notable for K 6.1 (5.1 on repeat).
- Imaging showed a T12 compression fracture with retropulsion.
CT head was negative for acute process. Chest, pelvis, hip,
tibial films were negative for fracture.
- Ortho spine was consutled and recommended non-operative
management with TLSO brace and outpatient f/u in 2 weeks. Per
discussion with ortho resident, fracture is not unstable and
patient may be activity as tolerated.
- Patient was given 4mg ondansetron, APAP 650mg, and olanzapine
5mg
Prior to transfer, vitals were T 97.8 HR 67 BP 112/67 RR 16 SpO2
99% on RA
Currently, the patient reports feeling well but endorses
fatigue. Her history is tangential and does not recall the
events of the fall. A significant portion of the history is
obtained from her daughter ___ who is present at the bedside.
Unfortunately, she is not aware of the specifics of the events
at ___ last night surrounding the fall.
Per ___ (RN at ___), the patient's fall was
unwitnessed, but someone had been in the room several minutes
previously. When she was found, she was consciousness, and at
her baseline mental status. There was no incontinence. She was
apparently complaining only of back pain and left leg pain.
Past Medical History:
- Dementia diagnosed with Alzheimer's type in ___.
- GERD
- Osteoporosis
- Hepatitis C, which has been untreated. According to the
patient's daughter, it is a form that responds poorly to
interferon.
- Patent foramen ovale.
- Right frontal/temporal meningioma for which she has had no
evaluation for the last ___ years.
- History of ___ diverticulum which caused a bowel
obstruction in ___. The patient had multiple bowel
obstructions
until the late ___ due to adhesions, but has not had an
obstruction since.
- Status post hysterectomy for unclear reasons.
- Left breast cancer, DCIS, status post reconstruction.
- Osteoarthritis.
- History of herpes zoster and possible postherpetic
neuralgia.
- Rosacea
Social History:
___
Family History:
The patient's mother and two of her sisters had
dementia. Father had a ___ diverticulum and died in his
___
of a bowel obstruction. Brother has multiple sclerosis and some
type of autoimmune disorder.
Physical Exam:
ADMISSION EXAM
--------------
VS - T 98.0 BP 154/75 HR 72 RR 17 SpO2 98% on RA
Weight: 49.2 kg
General: Appears well, alert, interactive
HEENT: Vision grossly impaired. Does not make direct eye
contact. Unable to tell how many fingers I am holidng up at 4
feet.
Neck: No JVD
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: Soft, nontender
Back: Minimal tenderness to palpation of lower thoracic spine.
No gross deformity.
Ext: Laceration on LLE is bandaged. Not examined underneath
bandage.
Neuro: Oriented to self only. CN II-XII grossly intact.
Sensation intact to light touch in upper and lower extremities
and is symmetric. No saddle anesthesia. Able to move all four
extremities without difficulty.
DISCHARGE EXAM
--------------
General: Appears well. She is alert and interactive
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: Soft, nontender
Back: Minimal tenderness to palpation of lower thoracic spine.
No gross deformity. No step-off or spinal process tenderness.
Ext: Laceration on LLE is bandaged with sutures in place. 8cm
wound approximately. R elbow has steri-strips covering smaller
laceration.
Neuro: Oriented to self only. CN II-XII grossly intact.
Sensation intact to light touch in upper and lower extremities
and is symmetric. She has 4+ strength throughout, appropriate
for her muscle bulk. There is no asymmetry in strength. Her DTRs
are 2+ in the patellae, 1+ in Achilles. Babinski is down
bilaterally.
Pertinent Results:
ADMISSION LABS
--------------
___ 11:00PM BLOOD WBC-7.5 RBC-4.41 Hgb-12.9 Hct-37.3 MCV-85
MCH-29.3 MCHC-34.7 RDW-14.5 Plt ___
___ 11:00PM BLOOD Neuts-73.3* ___ Monos-6.7 Eos-1.6
Baso-0.2
___ 11:00PM BLOOD ___ PTT-29.9 ___
___ 11:00PM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-135
K-6.1* Cl-100 HCO3-26 AnGap-15
___ 11:00PM BLOOD ALT-87* AST-163* LD(LDH)-757* AlkPhos-60
TotBili-0.8
___ 11:00PM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.8 Mg-2.1
___ 11:00PM BLOOD TSH-1.8
___ 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:16AM BLOOD K-5.1
___ 09:02PM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:02PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
___ 09:02PM URINE RBC-2 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
___ 09:02PM URINE CastHy-6*
IMAGING
-------
CT C-spine w/o contrast:
IMPRESSION:
Multilevel, multifactorial degenerative changes with no evidence
of acute
injury. Moderate canal narrowing at C4-5. Moderate to severe
foraminal narrowing at C4-5, C5-6 and mild to moderate at C6-7
level.
Correlate clinically to decide on the need for further workup or
followup. Nodules in the thyroid.
CT head w/o contrast:
IMPRESSION:
No acute intracranial hemorrhage or mass effect or acute
fracture.
Other details as above. Correlate clinically to decide on the
need for further workup or followup.
CT L-spine w/o contrast:
IMPRESSION:
Compression fracture of T12 as described in the thoracic spine
CT report. Consider MRI of the thoracic spine if not
contraindicated for better assessment of the acuity and
exclusion of an underlying lesion.
No evidence of acute lumbar spine fracture. Other details as
above.
CT T-spine w/o contrast:
IMPRESSION:
Compression deformity of the T12 vertebral body with burst
fracture and mild retropulsion of the superior aspect. CT is
limited for evaluation of
intrathecal components, and if there is concern for spinal cord
injury, MRI is recommended if not contra-indicated for better
characterization of the acuity and any underlying lesion and
intrathecal details.
Mild bulging ___ posteriorly indenting the thecal sac
outline series 603b, image 32. Diffuse osteopenia with
heterogeneous attenuation and multiple scattered lucent foci,
which may relate to fat deposition or marrow abnormality. This
can be better assessed with MRI if not contraindicated.
XRAY TIB/FIB (AP AND LAT) LEFT
IMPRESSION:
No evidence of fracture or dislocation.
XRAY PELVIS
IMPRESSION:
No evidence of fracture or dislocation of the pelvis or hips.
CHEST XRAY:
IMPRESSION:
Partial limited examination with no evidence of pneumonia.
----------
ECG: Sinus rhythm. A-V conduction delay. Left ventricular
hypertrophy. No
previous tracing available for comparison.
----------
MICROBIOLOGY: NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
2. Gabapentin 100 mg PO TID
3. Memantine 10 mg PO BID
4. meloxicam 15 mg oral QD
5. Omeprazole 20 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. ARIPiprazole 2.5 mg PO QHS
Discharge Medications:
1. ARIPiprazole 2.5 mg PO QHS
2. Memantine 10 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Sertraline 50 mg PO DAILY
5. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
6. Gabapentin 100 mg PO TID
7. meloxicam 15 mg ORAL QD
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#T12 compression fracture without spinal cord impingement
#Dementia, mixed alzheimer's and vascular type
#Chronic hepatitis C
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fall // rib injury, pneumonia
TECHNIQUE: AP upright and lateral radiographs
COMPARISON: None
FINDINGS:
The examination is partially limited by suboptimal patient positioning.No
strong evidence for pneumonia. No pleural effusion or pneumothorax. No
evidence of pulmonary edema. No definite rib fracture.
IMPRESSION:
Partial limited examination with no evidence of pneumonia.
Radiology Report
EXAMINATION: DX ABDOMEN W CROSS TABLE LATERAL
INDICATION: History: ___ with questionable findings on x-ray. Evaluate for
fracture.
TECHNIQUE: Single AP pelvis and diffuse is a right hip
COMPARISON: Pelvic radiographs from earlier on the same evening.
FINDINGS:
No fracture or dislocation of the right hip. Sacroiliac joints and lower
lumbar spine are unremarkable. Visualized bowel loops are normal.
IMPRESSION:
No fracture or dislocation of the right hip.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Laceration
Diagnosed with FX DORSAL VERTEBRA-CLOSE, OPEN WND KNEE/LEG/ANKLE, OPEN WOUND OF ELBOW, UNSPECIFIED FALL, TETANUS-DIPHT. TD DT
temperature: 99.0
heartrate: 70.0
resprate: 14.0
o2sat: 98.0
sbp: nan
dbp: nan
level of pain: 3
level of acuity: 3.0 | ASSESSMENT AND PLAN: Ms. ___ is an ___ year old woman with
mixed vascular-Alzheimer's dementia, chronic hepatitis C, and
osteoporosis who presents today from her locked dementia unit
for an unwitnessed fall and was found to have T12 compression
fracture and minor leg laceration.
#) FALL: Although unwitnessed, suspect mechanical fall given
vision difficulties and history of distal sensory
polyneuropathy. Lower suspicion for cardiac etiology. Her ECG
showed no ischemic changes. Urinalysis and toxicology screen
were unimpressive. She needs supervision when out of bed. She
sustained a minor left tibial laceration that required sutures.
These will either fall out spontaneously or can be removed in 1
week, whichever is sooner.
#) T12 COMPRESSION FRACTURE: Unclear chronicity. Radiology
thought "acute" but patient's daughter reports she has an old
vertebral compression fracture (films from ___
___ in ___. Per Spine surgery, activity is as
tolerated since this is not an unstable fracture. She was fitted
for ___ brace and should wear this when out of bed if
tolerated. She needs to follow up in clinic with Dr. ___ in 2
weeks.
#) OSTEOPOROSIS: Patient has a history of osteoporosis and
hypovitaminosis D. She She is not on a bisphosphonate. Unclear
of last DEXA. Consider starting calcium and vitamin D. Consider
discontinuing PPI if possible since it impairs both vitamin D
and calcium absorption (Am J Med. ___.
#) ALZHEIMER'S & VASCULAR DEMENTIA: Continued memantine and
galantamine.
#) CHRONIC HEPATITIS C: Has chronically elevated transaminases.
Untreated. No history of cirrhosis or evidence of synthetic
dysfunction by coagulation studies.
TRANSITIONAL ISSUES
-------------------
[]Sutures may be removed from left tibial laceration in ___
days
[]2mm left upper lobe nodule discovered incidentally on trauma
CT T-spine. There was no specific follow up recommended for this
nodule. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine / Aspirin
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with chronic pancreatitis ___ gallstones previous h/o
Puestow procedure (___) and h/o choledocholithiasis with recent
ERCP, sphincterotomy, and multiple stone extraction presents to
___ for abdominal pain. Pain was similar to last time
she was admitted (late ___ where they discovered she had
choledocholithiasis.
Per patient, she has been experiencing 1 day of colicky abd pain
with associated nausea and bilious emesis. Poor PO intake.
Diarrhea but no flatus. Pain has been getting worse since
presentation to ___. Last C-scope ___ years ago and per patient
no masses or polyps found.
At ___, CT scan performed showing SBO. Patient was
then transferred here for further management. NGT placed,
approximately ___ilious/contrast material out.
Past Medical History:
PMhx: chronic pancreatitis, gallstones, fibromylagia, chronic
abdominal pain, Hep C
PShx: Peustow, TAH, TKR
Social History:
___
Family History:
Cousin with U.C.
Physical Exam:
Admission PE:
98.3 65 146/85 18 95% RA
A+OX3, appears in pain
no scleral icterus
RRR
CTAB
Soft, ND, TTP epigastrium and R periumbilical and RLQ, previous
cheveron scar seen no hernias
guiac negative, no masses felt
Discharge PE: ___
GEN:AAOx3, NAD
HEART: RRR S1S2
LUNGS: CTAB
AB: mild tenderness left lower quadrant
EXT: peripheral pulses intact bilaterally
Pertinent Results:
___ 01:45PM BLOOD WBC-5.2 RBC-4.48 Hgb-13.6 Hct-37.3 MCV-83
MCH-30.3 MCHC-36.5* RDW-13.6 Plt ___
___ 05:09AM BLOOD WBC-5.0 RBC-4.48 Hgb-13.6 Hct-38.2 MCV-85
MCH-30.4 MCHC-35.6* RDW-13.5 Plt ___
___ 01:45PM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-116* UreaN-3* Creat-0.8 Na-138
K-4.4 Cl-111* HCO3-23 AnGap-8
___ 06:00AM BLOOD Glucose-130* UreaN-6 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-23 AnGap-14
___ 05:09AM BLOOD ALT-11 AST-20 AlkPhos-59 TotBili-0.5
___ 07:00AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.3
___ 06:00AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.1
___: chest x-ray:
No evidence of acute cardiopulmonary process. NG tube in
appropriate position.
___: abdominal x-ray:
On the current exam, the bowel gas pattern is nonspecific. Air
is seen in few scattered loops of non-dilated small bowel. Air
and stool are seen scattered throughout non-distended loops of
colon, including within the rectum. No free air is seen on the
decubitus film. Lung bases are not well evaluated on these
views.Multiple injection granulomas are again noted.
___: left venous duplex:
No evidence of deep vein thrombosis.
Medications on Admission:
Nexium 40", valium 10", oxycontin 80''', oxycodone 60 QID,
lyrica 100''', PEG, colace, MTV, Creon 10K TID
Discharge Medications:
1. Diazepam 10 mg PO BID
2. Docusate Sodium 100 mg PO BID
3. NexIUM Packet (esomeprazole magnesium) 40 mg Oral BID
4. OxycoDONE (Immediate Release) 60 mg PO Q6H:PRN pain
5. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
6. Pregabalin 100 mg PO TID
7. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with recent ERCP and partial small bowel
obstruction from outside institution CT, with NG tube placed for
decompression. Evaluate for location of the NG tube.
COMPARISON: CT abdomen from outside institution from ___.
TECHNIQUE: Frontal AP and lateral chest radiograph.
FINDINGS: The lungs are well expanded. Bibasilar streaky opacities likely
represent subsegmental atelectases. Cardiomediastinal and hilar contours are
unremarkable. There is no pleural effusion or pneumothorax. An NG tube ends
in the distal stomach.
IMPRESSION: No evidence of acute cardiopulmonary process. NG tube in
appropriate position.
Radiology Report
HISTORY: Partial small-bowel obstruction, question ileus.
ABDOMEN, TWO VIEWS INCLUDING LEFT DECUBITUS FILM WITH THE RIGHT SIDE UP.
On the current exam, the bowel gas pattern is nonspecific. Air is seen in few
scattered loops of non-dilated small bowel. Air and stool are seen scattered
throughout non-distended loops of colon, including within the rectum. No free
air is seen on the decubitus film. Lung bases are not well evaluated on these
views.Multiple injection granulomas are again noted.
Wet reading was provided to Dr. ___ at approximately 11:40 a.m. on
___ by Dr. ___ by phone.
Radiology Report
INDICATION: Left lower extremity swelling. Evaluation for DVT.
TECHNIQUE: Gray-scale and pulse wave Doppler of left lower extremity.
COMPARISON: None.
FINDINGS: There is normal respiratory phasicity in the common femoral veins
bilaterally. There is normal compressibility, flow, and augmentation of the
left common femoral, superficial femoral, and popliteal veins. Normal flow
and compressibility is demonstrated in the left posterior tibial and deep
peroneal veins.
IMPRESSION: No evidence of deep vein thrombosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V, +SBO
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 98.4
heartrate: 66.0
resprate: nan
o2sat: 98.0
sbp: 134.0
dbp: 83.0
level of pain: 13
level of acuity: 3.0 | The patient was admitted to the Acute Care Surgery Service on
___ with a partial small bowel obstruction. The patient was
transferred to the hospital floor for further care. The hospital
course was uneventful and the patient was discharged to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
phenytoin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
ERCP
___ GDA embolization
History of Present Illness:
___ yo M with PMH of seizure disorder s/p TBI, ETOH abuse and
T2DM presents with abdominal pain.
Patient initially presented to ___ with first right sided abd
pain ___ weeks ago that migrated to left sided abdominal pain of
2 days ago. He has had a similar pain in the past 6 months ago
for which he was hospitalized at ___ for alcohol
pancreatitis. At ___ he received IVF, IV Ativan and toradol.
Labs were notable for CO2 22, Anion gap 26, ALT 52, AST 134, T
bili 1.4, D bili .6, lipase >528, Trop <.03. ETOH 217.
A CT A/P showed possible choledocholithiasis and a RUQUS
reportedly showed a stone in the common bile duct though this
was not noted in the report. The patient was transferred to
___ for ERCP evaluation.
In ED initial VS: T 100.2 HR 118 BP 145/99 RR 20 O2 Sat 98% on
RA
Labs significant for: Lactate 6.2, HCO3 20, Anion gap 31, ALT
46, AST 106, Lipase 1142, AP 143, T bili 1.7, Direct bili .8
Patient was given:
Pip-Tazo 4.5g
2L NS
Dilaudid .5mg
Phenobarbital 740mg
Phenobarbital 180mg
1L LR
Consults: ERCP: NPO, Abx, IVF, admit East to ___, ERCP today
VS prior to transfer: 99.0 116 131/96 22 96% 2L NC
On arrival to the FICU, patient notes feeling pain is somewhat
better. notes pain had been ___ waxing/waning the past week,
but became more constant 2 days ago prompting ED. No fevers, but
had cold sweats mostly at night. 1 episode of nonbloody emesis
after clam dinner two nights ago. No diarrhea, hematochezia,
melena, dysuria, hematuria. No SOB, headache, changes to vision.
Past Medical History:
Seizure disorder s/p TBI in ___ after MVA
ETOH abuse
ETOH withdrawal w/ seizures
Alcoholic pancreatitis
T2DM
Social History:
___
Family History:
Family history of T2DM
No family history of seizure disorders
Physical Exam:
ON ADMISSION
VITALS: ___ 20 97% 2L NC
GENERAL: Alert, oriented, slightly tremulous and anxious
appearing
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachycardic, normal rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: psoriatic changes on lower legs bilaterally.
NEURO: A&Ox3, moving all extremities with purpose, somewhat
tremulous per above
EXAM(>=2)
___ 0749 Temp: 99.9 PO BP: 127/82 HR: 98 RR: 18 O2 sat: 95%
O2 delivery: RA FSBG: 110
non toxic, aox3
ctab
regular pulse
no abd tenderness to palpation
no peripheral edema.
Pertinent Results:
___ 09:24AM LACTATE-2.5*
___ 09:10AM ALT(SGPT)-37 AST(SGOT)-84* ALK PHOS-115 TOT
BILI-1.6* DIR BILI-0.9* INDIR BIL-0.7
___ 09:10AM CK-MB-2 cTropnT-<0.01
___ 09:10AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:10AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-30*
GLUCOSE-TR* KETONE-80* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:10AM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 06:50AM LACTATE-3.8*
___ 05:13AM LACTATE-6.2*
___ 05:00AM GLUCOSE-134* UREA N-4* CREAT-0.5 SODIUM-140
POTASSIUM-4.1 CHLORIDE-89* TOTAL CO2-20* ANION GAP-31*
___ 05:00AM ALT(SGPT)-46* AST(SGOT)-106* ALK PHOS-143*
TOT BILI-1.7* DIR BILI-0.8* INDIR BIL-0.9
___ 05:00AM LIPASE-1142*
___ 05:00AM ALBUMIN-4.2
___ 05:00AM WBC-6.6 RBC-3.69* HGB-13.1* HCT-38.4*
MCV-104* MCH-35.5* MCHC-34.1 RDW-12.6 RDWSD-48.6*
___ 05:00AM NEUTS-72.5* LYMPHS-15.4* MONOS-11.0 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-4.79 AbsLymp-1.02* AbsMono-0.73
AbsEos-0.00* AbsBaso-0.02
___ 05:00AM ___ PTT-27.7 ___
Imaging
CXR (___):
No prior chest radiographs available.
Symmetric bibasilar opacification could be pneumonia, but
atelectasis is more likely. Pleural effusions small if any. No
pneumothorax. Upper lungs clear. Heart size normal.
RUQ US (___):
1. Cirrhotic liver with evidence of portal hypertension
including ascites and splenomegaly. No focal lesions. No
specific sonographic findings to explain the patient's
increasing transaminitis.
2. Cholelithiasis without evidence of cholecystitis.
CT ap (___):
1. No evidence of active hemorrhage in the region of the
ampulla, adjacent to metallic CBD stent, or elsewhere in the
abdomen or pelvis.
2. Severe hepatic steatosis. Mild nonspecific contour
nodularity of the
liver. No focal hepatic lesion.
3. Trace ascites in the abdomen, most notable in the right lower
quadrant.
4. Splenomegaly, measuring 13.9 cm in length.
5. 7.1 x 4.1 cm intraparenchymal fluid collection in the
pancreatic tail.
Additional intraparenchymal fluid collection in the pancreatic
uncinate
process measuring 3.1 x 2.1 cm. Findings likely represent
necrotic fluid
collections from recent acute pancreatitis. Peripancreatic
stranding seen on outside CT from ___ has largely
resolved.
6. Wall thickening of the second portion of the duodenum, likely
postprocedural in nature. Stent extending from the proximal
common hepatic duct to the second portion of the duodenum,
containing air throughout.
7. Small bilateral pleural effusions, right greater than left,
with adjacent, compressive atelectasis.
Mesenteric arteriogram (___):
1. No large SMA branches to the region of the stent.
2. Patent celiac artery and GDA.
3. Post embolization demonstrates no residual flow in the GDA.
IMPRESSION:
Technically successful coil and Gel-Foam embolization of the
gastroduodenal artery.
CTA CHEST:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral upper lobe predominant multifocal pneumonia.
3. Small to moderate right greater than left bilateral pleural
effusions with
compressive atelectasis of the bilateral dependent lung bases.
4. Hepatic steatosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. glimepiride 4 mg oral DAILY
2. MetFORMIN (Glucophage) 500 mg PO BID
3. LevETIRAcetam 1250 mg PO BID
4. Humira (adalimumab) 00 mg subcutaneous Unknown
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
do not exceed 2 grams per day
2. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
3. Humira (___) 00 mg subcutaneous Frequency is Unknown
4. LevETIRAcetam 1250 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. HELD- glimepiride 4 mg oral DAILY This medication was held.
Do not restart glimepiride until follow up with your doctors
___:
Home
Discharge Diagnosis:
Acute necrotizing gallstone/alcohol pancreatitis
Alcoholic hepatitis
Bacterial pneumonia
GI bleeding
DM2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with pancreatitis and imaging c/f cholangitis at
OSH, being treated for alcohol withdrawal// ? Aspiration pneumonitis or
pneumonia ? Aspiration pneumonitis or pneumonia
IMPRESSION:
No prior chest radiographs available.
Symmetric bibasilar opacification could be pneumonia, but atelectasis is more
likely. Pleural effusions small if any. No pneumothorax. Upper lungs clear.
Heart size normal.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with hx EtOh abuse presenting with abdominal pain
s/p ERCP// Bedside as patient is clinically unstable, find cause of rising
Tbili
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Outside facility abdominal ultrasound from ___.
FINDINGS:
LIVER: The patent parenchyma is diffusely echogenic and coarsened with a
nodular contour in keeping with cirrhosis. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is small volume
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is cholelithiasis without gallbladder wall edema.
PANCREAS: Pancreas is not well seen, largely obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 13.6 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with evidence of portal hypertension including ascites and
splenomegaly. No focal lesions. No specific sonographic findings to explain
the patient's increasing transaminitis.
2. Cholelithiasis without evidence of cholecystitis.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old man with significant bleeding after sphinterotomy,
metal stent placed in ampulla to attempt tamponade but still bleeding, ___
requests mesenteric protocol prior to planned embolization// ___ year old man
with significant bleeding after sphinterotomy, metal stent placed in ampulla
to attempt tamponade but still bleeding, ___ requests mesenteric protocol prior
to planned embolization
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.6 s, 62.4 cm; CTDIvol = 3.4 mGy (Body) DLP = 209.9
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
3) Stationary Acquisition 5.1 s, 0.2 cm; CTDIvol = 86.0 mGy (Body) DLP =
17.2 mGy-cm.
4) Spiral Acquisition 9.6 s, 62.2 cm; CTDIvol = 6.9 mGy (Body) DLP = 425.3
mGy-cm.
5) Spiral Acquisition 9.6 s, 62.2 cm; CTDIvol = 6.9 mGy (Body) DLP = 425.3
mGy-cm.
Total DLP (Body) = 1,080 mGy-cm.
COMPARISON: Outside CT abdomen pelvis from ___ liver gallbladder
ultrasound from ___
FINDINGS:
VASCULAR:
There is no evidence of active extravasation in the region of the ampulla,
adjacent to metallic CBD stent, or elsewhere in the abdomen or pelvis.
There are mild atherosclerotic calcifications of the aortoiliac vessels.
There is no abdominal aortic aneurysm. The celiac artery, SMA, bilateral
renal arteries (noting an accessory left renal artery supplying the upper
pole) and ___ are patent, without high-grade stenosis. Portal vasculature is
patent.
LOWER CHEST: There are small bilateral pleural effusions, right greater than
left with adjacent compressive atelectasis. No concerning focal consolidation
is seen at the lung bases.
ABDOMEN:
HEPATOBILIARY: Liver is diffusely decreased in attenuation consistent with
severe steatosis. There is mild nodularity of the liver contour. No focal
hepatic lesions are identified. Evaluation of the gallbladder is limited due
to intraluminal contrast. There are multiple stones in the gallbladder. A
stent extends from the proximal common hepatic duct to the second portion of
the duodenum, containing air throughout. There is no pneumobilia.
PANCREAS: Pancreas is mildly atrophic with multiple calcifications seen on
noncontrast examination likely sequelae of prior episodes of pancreatitis.
The pancreatic parenchyma enhances heterogeneously. In the pancreatic tail,
there is a 7.1 x 4.1 cm intraparenchymal fluid collection. There is an
additional ill-defined intraparenchymal fluid collection, with internal
calcifications, in the pancreatic uncinate process, measuring 3.1 x 2.1 cm
(series 6; image 78). These likely represent necrotic fluid collections from
recent acute pancreatitis. There is no main pancreatic ductal dilatation.
Peripancreatic stranding seen on outside CT from ___ has largely
resolved.
SPLEEN: Spleen is enlarged measuring 13.9 cm in the coronal plane. No focal
splenic lesions are seen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: There is wall thickening of the second portion of the
duodenum, likely postprocedural in nature. Small bowel loops otherwise
demonstrate normal caliber, wall thickness and enhancement throughout. Colon
and rectum are otherwise within normal limits. Multiple prominent mesenteric
lymph nodes are seen, likely reactive.
There is trace ascites in the abdomen, most notable in the right lower
quadrant.
RETROPERITONEUM: Mildly enlarged left para-aortic lymph nodes measuring up to
10 mm in short axis (series 6; image 82) are also likely reactive.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: Visualized prostate and seminal vesicles are
unremarkable.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of active hemorrhage in the region of the ampulla, adjacent to
metallic CBD stent, or elsewhere in the abdomen or pelvis.
2. Severe hepatic steatosis. Mild nonspecific contour nodularity of the
liver. No focal hepatic lesion.
3. Trace ascites in the abdomen, most notable in the right lower quadrant.
4. Splenomegaly, measuring 13.9 cm in length.
5. 7.1 x 4.1 cm intraparenchymal fluid collection in the pancreatic tail.
Additional intraparenchymal fluid collection in the pancreatic uncinate
process measuring 3.1 x 2.1 cm. Findings likely represent necrotic fluid
collections from recent acute pancreatitis. Peripancreatic stranding seen on
outside CT from ___ has largely resolved.
6. Wall thickening of the second portion of the duodenum, likely
postprocedural in nature. Stent extending from the proximal common hepatic
duct to the second portion of the duodenum, containing air throughout.
7. Small bilateral pleural effusions, right greater than left, with adjacent,
compressive atelectasis.
Radiology Report
INDICATION: ___ year old man with significant bleeding after sphincterotomy,
metal stent placed in ampulla to attempt tamponade but still bleeding// ___
year old man with significant bleeding after sphincterotomy, metal stent
placed in ampulla to attempt tamponade but still bleeding
COMPARISON: CTA of the abdomen pelvis dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure and was assisted by Dr. ___.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 90 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, Versed, 1% lidocaine
CONTRAST: 100 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 43.1, 594 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Celiac arteriogram.
3. Superior mesenteric arteriogram.
4. Coil and Gel-Foam embolization of the gastroduodenal artery.
5. Right common femoral angiography and closure device placement.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the health care proxy.
The patient was then brought to the angiography suite and placed supine on the
exam table. A pre-procedure time-out was performed per ___ protocol. Both
groins were prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a micropuncture set at the level of the mid-femoral head. A
0.018 wire was passed easily into the vessel lumen. A small skin incision was
made over the needle. Then the inner dilator and wire were removed and a
___ wire was advanced under fluoroscopy into the aorta. The micropuncture
sheath was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire
was removed and the superior mesenteric artery was selectively cannulated and
a superior mesenteric arteriogram was performed.
The C2 catheter was exchanged for an SOS catheter which was used to select
celiac. A celiac arteriogram was performed. A renegade ___ microcatheter and
Transcend wire was advanced into the GDA down to the gastroepiploic artery.
The catheter was pulled back in a branch off the GDA was selected. This was
embolized with a 4 mm Concerto coil. Post angiogram demonstrates a good
result. The catheter was withdrawn into the main GDA and passed down to the
gastroepiploic origin. An 8 mm Concerto coil was deployed in this location.
While the coil initially appeared well seated, it subsequently embolized more
distally into the gastroepiploic artery. A 7 mm micro snare was used to snare
the coil and pull it back into the GDA. Despite this repositioning, the coil
again migrated more distally into the gastroepiploic artery. 10 mm and 12 mm
Concerto coils were used to embolize the GDA in addition to Gel-Foam. The
initial 10 mm coil was anchored in a GDA branch to prevent further chance of
embolization of the coil more distally. A 12 mm coil was used to embolize the
GDA more proximally. Post angiography from the common hepatic artery and
celiac demonstrated no residual flow into the GDA.
Right common femoral arteriogram demonstrated satisfactory puncture site for a
closure device. A 6 ___ Angio-Seal was successfully deployed the right
groin. +2 right common femoral pulse was noted post closure. There was no
hematoma. Additional manual pressure was held. A dressing was applied. The
patient tolerated the procedure well without any immediate complications.
FINDINGS:
1. No large SMA branches to the region of the stent.
2. Patent celiac artery and GDA.
3. Post embolization demonstrates no residual flow in the GDA.
IMPRESSION:
Technically successful coil and Gel-Foam embolization of the gastroduodenal
artery.
RECOMMENDATION(S): Continue to monitor for evidence of further bleeding.
Radiology Report
INDICATION: ___ year old man with pleurisy, low grade temps, hypoxia and sinus
tachycardia, concern for PE// rule out PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 4.7 mGy (Body) DLP = 0.9
mGy-cm.
2) Stationary Acquisition 5.2 s, 0.2 cm; CTDIvol = 44.8 mGy (Body) DLP =
9.0 mGy-cm.
3) Spiral Acquisition 5.2 s, 33.7 cm; CTDIvol = 6.4 mGy (Body) DLP = 210.1
mGy-cm.
Total DLP (Body) = 220 mGy-cm.
COMPARISON: None
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
Coronary artery calcifications noted. There is no evidence of pericardial
effusion. Moderate simple right greater than left pleural effusions are
noted, extending into the major fissures.
There are patchy and multifocal ground-glass opacities within the bilateral
upper lobes , middle lobe and lingula demonstrating a peribronchovascular
distribution suggestive of multifocal pneumonia. There is moderate
compressive atelectasis of the dependent lung bases bilaterally. Small
amount of debris is noted within the right upper trachea (06:49). The
remainder of the airways are patent to the subsegmental level.
Limited images of the upper abdomen is notable for hepatic steatosis and a
partially visualized biliary stent.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral upper lobe predominant multifocal pneumonia.
3. Small to moderate right greater than left bilateral pleural effusions with
compressive atelectasis of the bilateral dependent lung bases.
4. Hepatic steatosis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:51 pm, 1 minutes after
discovery of the findings.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Abd pain, ETOH
Diagnosed with Cholangitis
temperature: 100.2
heartrate: 118.0
resprate: 20.0
o2sat: 93.0
sbp: 145.0
dbp: 99.0
level of pain: 8
level of acuity: 2.0 | ___ history of TBI complicated by seizure disorder, psoriatic
arthritis on humira, active EtOH abuse, history of EtOH
pancreatitis and T2DM who has alcoholic hepatitis on suspected
alcoholic cirrhosis and necrotizing pancreatitis(alcohol vs
gallstone). Course complicated by ERCP with post sphincterotomy
bleed requiring metal stent and ___ embolization.
# Acute blood loss Anemia
# UGIB - post-sphincterotomy bleed, s/p GDA embolization on ___,
stabilized
# Acute Necrotizing pancreatitis - initially thought to be
gallstone pancreatitis for which he underwent ERCP with
sphincterotomy on ___, but now appears to be most likely
alcoholic pancreatitis. He is clinically improved and tolerating
diet with supportive care
-- outpatient ERCP/ACS followup, repeat ERCP in 4 weeks
-- He can follow up with GI closer to home post PCP follow up
# Decompensated alcoholic cirrhosis - new diagnosis, hepatology
following, appreciate recs. After initial concern about EtOH
hepatitis and rising ___ score he stabilized without need
for steroids.
--monitored nutrition, advanced diet to high-protein low-fat
diet per liver recs may need NGT if not meeting caloric targets,
but appears to be doing so now
--For his cirrhosis he needs outpatient follow up. For
pancreatitis ? CCY although alcohol favored over gallstone
pancreatitis.
#Sinus tachycardia #Fever #Hypoxia #Multifocal Pneumonia -
Initially now concern for infection though given concurrent
hypoxia and low grade fever, CTA chest performed showing PNA, no
PE. Placed on Vanco/CTX, narrowed to ceftriaxone and he will be
discharged on a 3d course of levofloxacin.
#ETOH abuse/withdrawal
Long history of ETOH abuse and recent admission for withdrawal
with possible withdrawal seizure treated with CIWA protocol. s/p
phenobarb loading and rescue dose in the ED.
- completed phenobarb protocol/taper |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"transfer from OSH for work up of abdominal mass."
Major Surgical or Invasive Procedure:
colonoscopy with biopsy
History of Present Illness:
This is a ___ yo M with aPMHx of colonic polyps (last c-scope was
___ years ago) and bacterial overgrowth s/p ___ year of antibiotics
who p/f ___ for further work up of an abdominal mass.
.
The patient began to have body aches and upper abdominal pain
about 7 days PTA. He tried multiple over the counter
medications and they were ineffective. The patient went on
vacation to ___ this weekend and on ___ the patient reports
having one blood streaked, solid stool. Then around noon, the
patient had ___ blood from his rectum. Denies frank
pre-syncopal symptoms. He then drove to ___ were
imaging revealed an ascending colonic mass with cecal dilation
and mild stranding. He was then transfered to ___ for further
work up.
.
Patient currently complain of mild stiffness in his upper
abdomen (RUQ/LUQ). Denies n/v. Is passing gas but has not had
a stool in 24 hours. His last stool was small and semiformed
with some blood. The patient denies w/l, f/c.
.
10 point ROS is otherwise negative, except per above
Past Medical History:
- HTN
- HLD
- ___ colonic polyps-last was ___ years ago, where multiple polyps
were removed at ___ Health-unsure of GI
physicians name
- ___ bleeding ulcer in UGI tract, s/p ___ year of antibiotics
-? ___ liver cysts in past
Social History:
___
Family History:
sister had colon cancer at ___ yo, died at ___
other sister had breast cancer and is still living
mother had breast cancer
father was healthy
Physical Exam:
Admission PE
98.2 129/86 79 18 98 RA
General: ___, in NAD
HEENT: OP clear, MM somewhat dry
CV: RRR, no RMG
Lungs: CTAB no wrr
Abdomen: obese, mild distention, mild TTP in RUQ, no palpable
HSM, active BS, no rebound, no guarding
Extremities: WWP, no CCE
Neuro: CN and MS grossly intact, strength and sensation also
grossly intact
Psyc: mood and affect wnl
Pertinent Results:
.
___ CT AP with IV contrast
-circumferential wall thickening of the mid right colon, cecum
is markedly distended measuring 12X9 cm, adjacent stranding
noted involving the cecum, multiple liver lesions, largest 2 cm
-imp: findings are most consistent with adenocarcinoma of the
mid-right colon with metastatic disease to the liver
.
labs at OSH wnl
.
.
___ data:
___ 06:20AM BLOOD WBC-8.5 RBC-4.56* Hgb-13.8* Hct-40.7
MCV-89 MCH-30.2 MCHC-33.8 RDW-13.7 Plt ___
___ 06:45AM BLOOD WBC-7.6 RBC-4.58* Hgb-14.1 Hct-40.7
MCV-89 MCH-30.9 MCHC-34.7 RDW-13.7 Plt ___
___ 08:03AM BLOOD WBC-8.4 RBC-4.73 Hgb-14.3 Hct-42.7 MCV-90
MCH-30.1 MCHC-33.4 RDW-13.6 Plt ___
___ 06:45AM BLOOD Neuts-61.9 ___ Monos-8.6 Eos-6.5*
Baso-0.3
___ 08:03AM BLOOD Neuts-60.5 ___ Monos-7.9 Eos-4.1*
Baso-0.5
___ 06:45AM BLOOD ___ PTT-27.9 ___
___ 08:03AM BLOOD ___ PTT-27.6 ___
___ 06:45AM BLOOD Glucose-105* UreaN-14 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-22 AnGap-17
___ 08:03AM BLOOD Glucose-129* UreaN-11 Creat-0.8 Na-137
K-4.3 Cl-98 HCO3-29 AnGap-14
___ 06:45AM BLOOD ALT-35 AST-37 AlkPhos-93 TotBili-0.8
___ 06:45AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
___ 06:45AM BLOOD CEA-158* AFP-4.1
___ 12:56PM BLOOD Lactate-0.7.
.
CXR ___:
SINGLE FRONTAL VIEW: There is mild cardiomegaly. The lungs are
clear. Aside from minimal atelectasis in the right base, there
is no pneumothorax or pleural effusion. There is no evidence of
free air within the abdomen
.
PATHOLOGY:
___
___
Pathology Examination
Name ___ Age Sex Pathology # ___ MRN#
___ ___ ___ Male ___
___
Report to: ___. ___
___ by: ___. ___, ___
SPECImEN SUBMITTED: gi bx (3 jars)
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___/___
DIAGNOSIS:
A Hepatic flexure mass biopsies: Adenocarcinoma. Slides reviewed
with Dr. ___.
___. Transverse colon polypectomy: Adenoma.
.
Colonoscopy:
Limitations: Obstructing mass when the hepatic flexure was
reached. The exam was interrupted.
Findings:
Protruding Lesions A single sessile 2 mm non-bleeding polyp of
benign appearance was found in the transverse colon. A
single-piece polypectomy was performed using a cold forceps in
the transverse colon. The polyp was completely removed.
Other Mass was noted at the hepatic flexure with surrounding
ulceration, edema and friability. The lumen was narrowed and
angulated and the scope could not traverse the lesion. Multiple
biopsies were obtained. Cold forceps biopsies were performed
for histology at the hepatic flexure.
Impression: Mass was noted at the hepatic flexure with
surrounding ulceration, edema and friability. The lumen was
narrowed and angulated and the scope could not traverse the
lesion. Multiple biopsies were obtained. (biopsy)
Polyp in the transverse colon (polypectomy)
Otherwise normal colonoscopy to hepatic flexure
Recommendations: Rush pathology results
follow up per inpatient gi team recommendations
Oncology consult
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 40 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Pravastatin 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
lower GI bleeding ___ to colon mass
suspicion for colon ca and possible liver metastasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Patient with abdominal mass and tenderness. Evaluate for
free air.
SINGLE FRONTAL VIEW: There is mild cardiomegaly. The lungs are clear. Aside
from minimal atelectasis in the right base, there is no pneumothorax or
pleural effusion. There is no evidence of free air within the abdomen.
Gender: M
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, ABDOM/PELV SWELL/MASS UNSP SITE
temperature: 98.6
heartrate: 82.0
resprate: 16.0
o2sat: 97.0
sbp: 135.0
dbp: 54.0
level of pain: 6
level of acuity: 2.0 | This is a ___ yo M with a PMHx colonic polyps s/p multiple
removals all of which were benign in the past per report,
gastric overgrowth c/b UGI ulcer s/p ___ year of antibiotics who
p/w 1 week of abdominal pain progressive to bloody stools with a
CT scan from OSH that showed a narrowing in the ascending colon
with cecal dilation and mild stranding without free air on CXR,
normal lactate.
.
# Ascending colonic adenocarcinoma with Hematochezia. Etiology
suspected was colonic adenocarcinoma given radiographic
appearance. Other considerations could include lymphoma vs.
adenoma. Colonscopy was performed on ___ confirming
suspicion of colonic adenocarcinoma. Biopsy was taken during
admission and returned POSITIVE for adenocarcinoma just after pt
discharge. Pt's laboratories remained normal and his diet was
successfully advanced without complication. Pt reported normal
BM prior to ___. There was no evidence of any GI bleeding during
admission. CT scan at ___ raised concern for hepatic metastasis.
See below. Pt and family wished to undergo colorectal surgical
evaluation at ___. Pt's family arranged for this
appointment which reportedly occurred ___ at 2Pm. In
addition, pt's family wished to investigate which oncologist to
follow up with, preferring to f/u at ___. Pt and family
were provided with contact information to set up an appointment
at ___ or ___ if desired.
SOcial work was consulted during admission.
-Attempting to call pt's 2 listed telephone numbers after
discharge to relay the pathology results. Left message for the
patient to return my call. In addition, called over to PCP's
office but the office was closed for the day.
.
# hypodensities in liver-per family report this had been noticed
in the past. This was noted on OSH CT imaging. Liver function,
per laboratory testing appeared intact. DDx includes cysts vs.
metastasis. Pt may require a liver biopsy in the outpatient
setting to confirm metastatic disease. Pt wished to follow up at
___ and ___. Pt will f/u with PCP for ongoing care as well.
CEA was elevated. AFP WNL.
.
# HTN-continued ACEI
.
# HLD-continued statin
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ with CABGx3 (___), anterior MI (___),
ischemic CM s/p ICD (EF ___ was ___, DM2, DVT (off
coumadin ___ noncompliance), chronic chest and R leg pain, and
multiple prior ED visits and admissions for syncope and/or chest
pain, now presenting with chest pain.
He has had intermittent pain in the L chest for 2 days. He says
this pain is equivalent to pain he has had for "some time", but
has gotten worse over the last few days. The pain is not
provoked or relieved by exercise (walking), and is worse when
leaning forward. He reports that it is relieved by oxycodone but
not nitryglycerin. Notably he says he was having this pain when
he had a syncopal episode in church 2 weeks ago, leading to his
most recent admission. The pain is ___, though at times worse
than the ___ pain in his R leg. No radiation to anywhere else
in the body. He endorses pain in his R leg which is related to
his past MVA and unchanged from baseline. He endorses no fevers,
no cough, no abd pain, no n/v.
Notably, the patient has >20 hospital admissions over the past
year, with repeatedly negative workups. He was last discharged
from ___ 10 days ago. He was admitted for syncope. At that
time the patient had unchanged EKG, negative troponins x 2,
pacemaker interrogation revealed normal function, and no events
on telemetry monitoring.
He had an unchanged stress test in ___, and a negative CTA
performed in ___.
In the ED, initial VS were HR 76, RR 18, BP 116/76, O2 99RA. He
was afebrile. He received aspirin 325 x2. Troponin-T was <0.01
x2. EKG revealed delayed R-wave progression, T wave inversions
in I and AVL as well as lateral T-wave changes that were
unchanged from his exam on ___. Vital signs remained stable, and
his chest pain improved. He was admitted to the general medicine
floor for further workup and monitoring.
On arrival to the floor, patient reports his chest pain has
improved. Still complains of leg pain.
He reports drinking "20 glasses" of water per day due to a
desire to avoid drinking soda and juice, which he knows is bad
for him.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Mood is good. Denies recent stressors.
Denies desire to hurt self or others.
All other 10-system review negative in detail.
Past Medical History:
- CAD s/p MI in ___ and CABG for 3-VD in ___
- CHF with LVEF of ___ in per ___ TTE. Patient now s/p
ICD.
- Delusional and affective thought disorder
- Hypertension
- Hyperlipidemia
- Type 2 diabetes. Not currently on medications.
- History of LV thrombus. Failed Coumadin per ___ notes in ___
due to noncompliance and supratherapeutic INR's
- History of DVT and PE in ___. Previously on Coumadin.
- Chronic chest pain due to sternotomy
- Chronic back pain
- MVC (struck pedestrian) in ___
- Possible PTSD due to MVC
- Diverticulosis
- History of thyroid nodule
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM:
VS 98.0 115/70 74 16 100RA
GENERAL: Lying in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CHEST: RRR, S1/S2, no murmurs, gallops, or rubs. Endorses
tenderness over R pectoralis muscle. Denies pain at sternotomy
scar or over implanted pacemaker (overlies LUQ of L pectoralis).
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Moves all extremities, no cyanosis, clubbing or
edema appreciated. Right lower extremity is wrapped, and the
patient does not allow it to be unwrappped to be examined (this
is location of his previous injury). Able to move foot and toes.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
PSYCH: Alert and oriented to person and location, but not day of
week (___). Recall ___ ("ball, table, truth") after 5
minutes. Good fund of general knowledge (names past 3
presidents). Impaired ability to make abstractions (when asked
similarity between apple and orange, says "you can peel an
orange and just eat an apple", asked to explain "people in glass
houses shouldn't throw stones" says "you'll break something").
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
VS 97.9 109/62 69 16 100RA
GENERAL: Lying in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, nontender supple
neck, no LAD, no JVD
CHEST: RRR, S1/S2, no murmurs, gallops, or rubs.
Stable tenderness over R pectoralis muscle. No pain elsewhere
over chest.
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Nondistended, +BS, nontender in all quadrants, no
rebound/guarding.
EXTREMITIES: Moves all extremities, no cyanosis, clubbing or
edema appreciated. Right lower extremity is wrapped, and the
patient does not allow it to be unwrappped to be examined (this
is location of his previous injury). Able to move foot and toes.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
PSYCH: A/O x2, oriented to day of week but not date.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 07:25PM cTropnT-<0.01
___ 08:40AM cTropnT-<0.01
___ 02:30AM cTropnT-<0.01
___ 02:30AM GLUCOSE-131* UREA N-20 CREAT-1.6* SODIUM-136
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-28 ANION GAP-10
___ 02:30AM ALT(SGPT)-10 AST(SGOT)-15 ALK PHOS-58 TOT
BILI-0.3
___ 02:30AM LIPASE-60
___ 02:30AM ALBUMIN-4.3
___ 02:30AM WBC-5.6 RBC-4.07* HGB-11.6* HCT-35.9* MCV-88
MCH-28.5 MCHC-32.3 RDW-13.6
___ 02:30AM ___ PTT-28.8 ___
___ 06:55AM BLOOD WBC-3.9* RBC-4.15* Hgb-11.6* Hct-36.3*
MCV-87 MCH-27.9 MCHC-31.9 RDW-13.3 Plt Ct-UNABLE TO
___ 06:55AM BLOOD Glucose-104* UreaN-21* Creat-1.4* Na-138
K-4.2 Cl-105 HCO3-25 AnGap-12
___ 06:55AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0
CXR ___: No acute process
EKG ___:
Sinus rhythm. Extensive ST segment changes prominently in leads
V1-V4
suggestive of anterior wall myocardial infarction. Compared to
the previous tracing of ___ ST segment changes are similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Benztropine Mesylate 1 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Haloperidol 5 mg PO BID
6. Lidocaine 5% Ointment 1 Appl TP TID:PRN lower extremity pain
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H PRN pain
11. Pantoprazole 40 mg PO Q24H
12. Psyllium 1 PKT PO DAILY:PRN constipation
13. QUEtiapine Fumarate 50 mg PO QHS
14. Sertraline 200 mg PO DAILY
15. Senna 8.6 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Benztropine Mesylate 1 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Haloperidol 5 mg PO BID
6. Lidocaine 5% Ointment 1 Appl TP TID:PRN lower extremity pain
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H PRN pain
11. Pantoprazole 40 mg PO Q24H
12. Psyllium 1 PKT PO DAILY:PRN constipation
13. QUEtiapine Fumarate 50 mg PO QHS
14. Senna 8.6 mg PO BID
15. Sertraline 200 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
# Musculoskeletal chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with chest pain.
COMPARISON: ___.
FINDINGS: AP upright and lateral views of the chest were obtained.
Cardiomediastinal silhouette is stable. A dual-chamber pacemaker is unchanged
in position. Lung volumes are low. No focal consolidation, pleural effusion,
or pneumothorax.
IMPRESSION: No acute process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, AORTOCORONARY BYPASS
temperature: 98.0
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 106.0
dbp: 66.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ is a ___ with CABGx3 (___), anterior MI (___),
ischemic CM s/p ICD (EF ___ was ___, DM2, DVT (off
coumadin ___ noncompliance), chronic chest and R leg pain, and
multiple prior ED visits and admissions for syncope and/or chest
pain, now presenting with chest pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right face and arm numbness and weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ w/ Afib, CAD s/p 4x CABG, HLD, HTN who
was taken of warfarin 3 weeks ago in setting of normal Holter
and two days ago presented with Afib w/ RVR in setting of
pneumonia and restarted on warfarin, who presents with 10
minutes of right finger numbness and right facial weakness.
The patient was in his usual state of health when two days ago
(___), he presented to the BI ED for tachycardia and fever,
and found to have a right lower lobe pneumonia and Afib w/ RVR.
He was discharged yesterday on levofloxacin and has been
afebrile since.
This morning he was in his usual state of health when he noted
diffuse right finger anesthesia, not including palm or arm.
This started at around 10:00am, and when he told his wife, she
noted a few minutes of right lower facial weakness. He also
had difficulty lifting a bag with his right hand, unclear if
there was superimposed weakness. There was also a lower pitch
to his voice. All symptoms resolved after 10 minutes. After
calling his cardiologist, he was recommended to come to the ED
for evaluation.
Review symptoms positive for recent fevers, previous
palpitations but none today, chronic hearing loss.
On review of systems, the patient denies the following:
- Neurologic: headache, confusion, difficulty producing speech,
difficulty understanding speech, vision loss, diplopia, vertigo,
dysarthria, dysphagia, focal limb weakness, sensory loss, gait
imbalance.
- Constitutional: fever, rigors, night sweats, unintentional
weight loss.
- Cardiovascular: chest pain, lightheadedness.
- Gastrointestinal: nausea, emesis, diarrhea, constipation.
- Genitourinary: dysuria, urinary urgency, urinary
incontinence.
- Ear, Nose, Throat: tinnitus, rhinorrhea, odynophagia.
- Hematologic: bleeding, easy bruising.
- Musculoskeletal: arthralgia, myalgia.
- Psychiatric: anxiety, depression.
- Respiratory: dyspnea, cough, hematemesis.
- Skin: rash, new skin lesions.
Past Medical History:
CAD, s/p small MI ___ (Med RX/No prior catheterization)
Angina
Right Frontal Ischemic Stroke ___ (No residual deficits)
Small infrarenal AAA
Hypertension
Dyslipidemia
Moderate Aortic Regurgitation
PFO
Sleep apnea (no cpap currently)
Osteoporosis
Gout
Social History:
___
Family History:
Premature coronary artery disease- Father died at age ___ from
heart disease in ___
Physical Exam:
Admission Physical Examination:
VS T: 99.0 HR: 70 BP: 127/88 RR: 18 SaO2: 100% RA
- General/Constitutional: Lying in bed comfortably,
well-appearing.
- Eyes: Round, regular pupils. No conjunctival icterus, no
injection.
- Ear, Nose, Throat: No oropharyngeal lesions. Normal
appearance of the tongue.
- Neck: No meningismus.
- Musculoskeletal: Range of motion with neck rotation full
bilaterally. No focal spinal tenderness.
- Skin: No rashes. No concerning lesions appreciated.
- Cardiovascular: Regular rate.
- Respiratory: No increased work of breathing, retractions or
wheeze.
- Gastrointestinal: Nontender. Nondistended.
- Psychiatric: Mood congruent with affect. Intact insight.
___ Stroke Scale - Total [0]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 0
3. Visual Fields - 0
4. Facial Palsy - 0
5a. Motor arm, left - 0
5b. Motor arm, right - 0
6a. Motor leg, left - 0
6b. Motor leg, right - 0
7. Limb Ataxia - 0
8. Sensory - 0
9. Language - 0
10. Dysarthria - 0
11. Extinction and Neglect - 0
Neurologic Examination:
- Mental Status - Awake, alert, oriented x 3. Attention to
examiner easily attained and maintained. Concentration
maintained when recalling months backwards. Recalls a coherent
history. Structure of speech demonstrates fluency with full
sentences, intact repetition, and intact verbal comprehension
(though with
some repetition due to language barrier). Content of speech
demonstrates intact naming (high and low frequency) and no
paraphasias. Normal prosody. No dysarthria. No apraxia. No
evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - [II] PERRL 4->2 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] V1-V3 without
deficits to light touch bilaterally. [VII] No facial movement
asymmetry with forced eyelid closure or volitional smile. [VIII]
Chronic difficulty hearing finger rub bilaterally. [IX, X]
Palate elevation symmetric. [XI] SCM/Trapezius strength ___
bilaterally. [XII] Tongue midline.
- Motor - Normal bulk and tone. No pronation, no drift. No
orbiting with arm roll. No tremor or asterixis. ___ strength in
the proximal and distal UEs and LEs.
- Sensory - No deficits to light touch or pinprick in upper
extremities. Feet with intact sensation to pinprick
bilaterally. Decreased vibration sense in right foot 0 seconds,
6 seconds in left foot. Bilateral decreased proprioception, R
worse than L. No extinction to double simultaneous tactile
stimulation.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L ___ 1 1
R ___ 1 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing.
- Gait - Normal initiation. Narrow base. Normal stride length
and arm swing. Stable without sway. No Romberg. Mild
difficulty with tandem gait.
=============
Discharge Physical Exam:
General exam: unremarkable
Neurologic exam: MS intact. CN intact bilaterally. Full strength
in the proximal and distal UEs. Reflexes diminished
symmetrically (1+ throughout). Coordination intact. Independent,
narrow-based gait.
Pertinent Results:
___ 03:00PM BLOOD WBC-9.9 RBC-4.85 Hgb-11.5* Hct-37.7*
MCV-78* MCH-23.7* MCHC-30.5* RDW-18.7* RDWSD-50.8* Plt ___
___ 03:00PM BLOOD Neuts-70.2 Lymphs-18.2* Monos-10.5
Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.93* AbsLymp-1.80
AbsMono-1.04* AbsEos-0.04 AbsBaso-0.02
___ 04:45AM BLOOD ___
___ 04:45AM BLOOD Glucose-82 UreaN-29* Creat-1.4* Na-140
K-4.5 Cl-107 HCO3-22 AnGap-16
___ 04:45AM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD %HbA1c-5.4 eAG-108
___ 04:45AM BLOOD Triglyc-83 HDL-34 CHOL/HD-4.3 LDLcalc-94
___ 04:45AM BLOOD TSH-2.6
=============
IMAGING:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage,
edema, or mass. Mild prominence of ventricles and sulci is
likely related to age related involutional changes. The basilar
cisterns are patent, and there is otherwise good preservation
gray-white matter differentiation.
The visualized portion of the paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion,
or aneurysm formation. The dural venous sinuses are patent.
Note is made of a fetal type origin of the right PCA. The
posterior circulation is otherwise well preserved. Incidental
note
is made a fenestrated proximal basilar artery, immediately at
the junction of the vertebral arteries.
CTA NECK:
The carotid and vertebral arteries and their major branches
appear normal with no evidence of stenosis or occlusion. There
is no evidence of internal carotid stenosis by NASCET criteria.
Mild atherosclerotic calcification is seen at the carotid
siphons bilaterally.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria.
IMPRESSION:
1. No acute intracranial abnormalities identified.
2. Unremarkable CTA of the head, with a patent circle of ___.
3. Unremarkable CTA of the neck, without evidence of internal
carotid artery stenosis by NASCET criteria.
MRI Brain:
Linear cortical left parietal restricted diffusion, with
questioned minimal T2/FLAIR hyperintensity, without definite
associated increase susceptibility is noted (see 3, 04:24, 9,
10, 11: 18).
Right frontal linear T2 and FLAIR hyperintensity is noted.
There is no evidence of hemorrhage or midline shift.
There is prominence of the ventricles and sulci suggestive
involutional changes.
Minimal bilateral ethmoid air cell mucosal thickening.
IMPRESSION:
1. Left parietal acute to subacute infarct without definite
hemorrhagic transformation, as described.
2. Right frontal nonspecific white matter changes, which may
represent microangiopathic changes are sequela of prior trauma
or infarct.
3. Minimal paranasal sinus disease as described.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levofloxacin 750 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Allopurinol ___ mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Docusate Sodium 100 mg PO BID
7. Warfarin 2 mg PO DAILY16
8. Metoprolol Succinate XL 150 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 80 mg SC BID
Start: ___, First Dose: First Routine Administration Time
use until INR is ___
RX *enoxaparin 80 mg/0.8 mL 80 mg subcutaneous twice a day Disp
#*1 Package Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Levofloxacin 750 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Metoprolol Succinate XL 150 mg PO DAILY
9. Warfarin 2 mg PO DAILY16
10. HELD- Aspirin EC 81 mg PO DAILY This medication was held.
Do not restart Aspirin EC until you discontinue lovenox
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with recent admission for RLL PNA, here w episode of
R hand numbness and R facial droop // Eval for acute process, change in PNA,
stroke
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy and CABG. Tortuous, unfolded aorta
is similar in appearance compared the prior study. The cardiac silhouette is
stable.No focal consolidation is seen. There is minor left base atelectasis.
There is persistent blunting of the right costophrenic angle suggesting a
trace right pleural effusion. No overt pulmonary edema.
IMPRESSION:
Trace right pleural effusion again seen. No definite focal consolidation.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with recent admission for RLL PNA, here w episode of
R hand numbness and R facial droop // Eval for acute process, change in PNA,
stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 5.4 s, 42.4 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,357.7 mGy-cm.
Total DLP (Head) = 2,400 mGy-cm.
COMPARISON: MRI of the brain from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
Mild prominence of ventricles and sulci is likely related to age related
involutional changes. The basilar cisterns are patent, and there is otherwise
good preservation gray-white matter differentiation.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent. Note is made of a fetal type origin of the right
PCA. The posterior circulation is otherwise well preserved. Incidental note
is made a fenestrated proximal basilar artery, immediately at the junction of
the vertebral arteries.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria. Mild atherosclerotic calcification is seen at
the carotid siphons bilaterally.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. No acute intracranial abnormalities identified.
2. Unremarkable CTA of the head, with a patent circle of ___.
3. Unremarkable CTA of the neck, without evidence of internal carotid artery
stenosis by NASCET criteria.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old male with history of Afib, multiple cardiovascular
risk factors, now with transient right hand numbness, and right facial and
hand weakness. Evaluate for acute infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ head and neck CTA.
___ noncontrast brain MRI/ MRA.
FINDINGS:
Linear cortical left parietal restricted diffusion, with questioned minimal
T2/FLAIR hyperintensity, without definite associated increase susceptibility
is noted (see 3, 04:24, 9, 10, 11: 18).
Right frontal linear T2 and FLAIR hyperintensity is noted.
There is no evidence of hemorrhage or midline shift.
There is prominence of the ventricles and sulci suggestive involutional
changes.
Minimal bilateral ethmoid air cell mucosal thickening.
IMPRESSION:
1. Left parietal acute to subacute infarct without definite hemorrhagic
transformation, as described.
2. Right frontal nonspecific white matter changes, which may represent
microangiopathic changes are sequela of prior trauma or infarct.
3. Minimal paranasal sinus disease as described.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 13:39 into the Department of Radiology critical
communications system for direct communication to the referring provider.
The findings were discussed with ___, M.D. by ___, M.D.
on the telephone on ___ at 1:41 ___, 10 minutes after discovery of the
findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Numbness
Diagnosed with Transient cerebral ischemic attack, unspecified
temperature: 99.0
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 88.0
level of pain: 0
level of acuity: 2.0 | ___ w/ Afib, CAD s/p 4x CABG, HLD, HTN, and previous stroke in
___ and TIA in ___ who presented with 10 minutes of right face
and arm numbness and weakness, found to have a small ischemic
stroke. He was just restarted on Coumadin 2 days ago and his INR
was subtherapeutic. He will be bridged with lovenox until his
INR is ___. While taking lovenox, his aspirin is being held, but
can be restarted once the lovenox is stopped. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
___: Open reduction, internal fixation anterior pelvic
ring and posterior pelvic ring injury with 7.3 mm screws
History of Present Illness:
This patient is a ___ year old male brought in by medics
light from the scene after a reported 30 foot fall through
skyline all performing snow maintenance building roof.
Extrication time was approximately 40 minutes from the
building. The patient was brought in with concern for pelvis
injury. He is wearing a cervical collar, awake, alert, and
oriented x3. Positive LOC according to bystanders. Patient
is ___ only. He complains of abdominal pain and
mild shortness of breath. Vital signs are normal on arrival.
Has received 100 mcg of fentanyl prior to arrival. He denies
significant headache, vision changes, nausea, vomiting. He
states he has no medical history, allergies, medications, or
surgical history.
Past Medical History:
none
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAMINATION
O(2)Sat: 99 Normal
Constitutional: Mildly uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nondistended, mildly diffusely tender without
guarding. No bruising or flank pain
Extr/Back: No cyanosis, clubbing or edema, no obvious
deformity. Pelvis appears stable
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
PE on discharge:
VS: 98.3, 79, 110/40, 18, 98%ra
Gen: A&O x3, NAD
Chest: LS ctab
CV: HRR, normal s1/s2
Abd: soft, NT/ND. left pelvic and left hip staples
Ext: no edema
Pertinent Results:
___ 06:20AM BLOOD WBC-4.0 RBC-3.13* Hgb-9.9* Hct-27.5*
MCV-88 MCH-31.7 MCHC-36.1* RDW-13.1 Plt ___
___ 07:55PM BLOOD Hct-27.3*
___ 01:00PM BLOOD Hct-26.9*
___ 06:05AM BLOOD WBC-4.3 RBC-2.97* Hgb-9.3* Hct-26.0*
MCV-88 MCH-31.4 MCHC-35.8* RDW-12.8 Plt ___
___ 12:13AM BLOOD Hct-27.7*
___ 07:28PM BLOOD Hct-30.4*
IMAGING:
CT C-SPINE
1. No evidence of fracture or dislocation.
CT HEAD
No evidence of acute intracranial abnormality.
CT CHEST; CT ABD & PELVIS
1. Moderate right pneumothorax and pneumomediastinum. Multiple
right lung
contusions.
2. Grade 2 liver injury. Small amount of perihepatic hemorrhage
tracking
inferiorly into the pelvis.
3. Possible tiny contusion in the superior aspect of the spleen.
4. Nondisplaced right seventh rib fracture. Fractures of the
superior inferior left pubic rami. Fractures of the left sacral
ale and left ischial tuberosity.
WRIST XRAY
No fracture or dislocation. Carpal rows appear intact. No
radiopaque foreign body. Soft tissues unremarkable.
CXR ___
As compared to the previous image, there is no substantial
change in dimension of the right apical pneumothorax. The
patient shows no evidence of tension. The pre described subtle
right lower lung parenchymal opacity has completely resolved, a
small atelectasis in the infra hilar right lung regions
persists. Unremarkable left lung. Normal size of the cardiac
silhouette. No pneumonia or pleural effusions.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
4. Outpatient Physical Therapy
Medical Dx / ICD9: 959.9/trauma 850.9/Concussion
Activity Orders: L ___: TDWBING, R ___: WBAT
Goals: Gait training
5. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc once a day Disp #*14
Syringe Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1: Fall from 30 feet
2: Grade 2 liver laceration, small splenic injury
3: Anterior and posterior pelvic ring fracture, left-sided
4: moderate left-sided pneumothorax with pulmonary contusion
5: Right 7th rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS (AP, INLET AND OUTLET) IN O.R.
INDICATION: PELVIS FX
TECHNIQUE: 51 intraoperative fluoroscopic spot images of the pelvis were
obtained without the radiologist present. Total fluoroscopy time is 01:00 29
seconds.
COMPARISON: Radiographs of the pelvis and CT of the torso ___.
FINDINGS:
Sequential images demonstrate localizing devices over the right inferior pubic
ramus, the sacrum and the left iliac bone with subsequent fixation of left
sacroiliac joint diastasis with a lag screw and fixation of a fracture through
the left superior pubic ramus with an additional lag screw. There is no
evidence of hardware complication. There is redemonstration of a left inferior
pubic ramus fracture.
IMPRESSION:
Open reduction internal fixation of a fracture through the left superior pubic
ramus and left sacroiliac joint diastasis. Please see the operative report for
further details.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with fall from 30 ft // eval ptx
IMPRESSION:
AS COMPARED TO THE PREVIOUS RADIOGRAPH FROM EARLIER THE SAME DATE, A SMALL
RIGHT APICAL PNEUMOTHORAX IS SIMILAR TO THE PRIOR STUDY. RIGHT LOWER LOBE
OPACITY HAS PARTIALLY RESOLVED, AND REMAINDER OF THE LUNGS AND PLEURA ARE
UNCHANGED.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with +LOC, polytrauma, grade 2 liver lac, infr
pubic rami/iliac frx, R PTX, R 7th rib frx // Evaluation of pneumothorax
COMPARISON: ___.
IMPRESSION:
As compared to the previous image, there is no substantial change in dimension
of the right apical pneumothorax. The patient shows no evidence of tension.
The pre described subtle right lower lung parenchymal opacity has completely
resolved, a small atelectasis in the infra hilar right lung regions persists.
Unremarkable left lung. Normal size of the cardiac silhouette. No pneumonia
or pleural effusions.
Radiology Report
INDICATION: ___ year old man with fall from 30 ft // eval fracture
TECHNIQUE: Three views right wrist.
COMPARISON: None
FINDINGS:
No fracture or dislocation. Carpal rows appear intact. No radiopaque foreign
body. Soft tissues unremarkable.
IMPRESSION:
No fracture or dislocation of the wrist.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall from 30 ft // trauma
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 891 mGy-cm
CTDI: 53 mGy
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration. The basal cisterns are
patent. Gray-white matter differentiation is preserved.
No osseous abnormalities seen. There is mucosal thickening in the right
frontal sinus and frontoethmoidal recess. There is opacification of bilateral
anterior ethmoid air cells. There is minimal mucosal thickening in the
sphenoid sinuses and mild mucosal thickening in the partially imaged maxillary
sinuses. The mastoids are underdeveloped but clear. The middle ear cavities
are clear.
IMPRESSION:
Minimal paranasal sinus inflammatory changes. Otherwise normal study.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall from 30 ft // trauma trauma
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 37 mGy
DLP: 817 mGy-cm
COMPARISON: None
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal narrowing. There is no evidence of infection
or neoplasm.
There is partially imaged right apical pneumothorax. The palatine tonsils are
enlarged with several tonsilliths. There are prominent but symmetric cervical
lymph nodes likely within normal limits for patient's age.
IMPRESSION:
1. No evidence of fracture or dislocation. Right apical pneumothorax
partially imaged.
2. Enlarged palatine tonsils with several tonsilliths.
3. Prominent cervical all lymph nodes likely within normal limits for
patient's age.
Radiology Report
INDICATION: History: ___ with fall from 30 ft // trauma
TECHNIQUE: Frontal radiographs of the chest and pelvis.
COMPARISON: CT of the torso performed on ___ at 11:42am.
FINDINGS:
CHEST: The lungs are well expanded and clear. Cardiomediastinal and hilar
contours are unremarkable. There is no pneumothorax, pleural effusion, or
consolidation. No acute displaced rib fractures are identified.
PELVIS: Frontal radiograph of the pelvis demonstrates fractures involving the
left inferior pubic ramus and left iliac bone, and through the superior pubic
ramus as well.
IMPRESSION:
1. Fractures of the left inferior pubic ramus, left iliac bone, and superior
pubic ramus.
2. No acute cardiopulmonary process.
Radiology Report
INDICATION: History: ___ with fall from 30 ft // trauma
TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen
and pelvis after administration of 130 cc of Omnipaque IV contrast.
Multiplanar axial, coronal and sagittal images were generated.
DOSE: Total body DLP: 445 mGy-cm
COMPARISON: None
FINDINGS:
CT CHEST WITH CONTRAST: Partially imaged thyroid unremarkable. No
lymphadenopathy. Esophagus normal. Heart size is normal without pericardial
effusion. Aorta and main thoracic vessels wall opacified. Main pulmonary
artery is normal in caliber. There is pneumomediastinum.
There is moderate right pneumothorax. Multiple rounded peripheral opacities
throughout the right lung are compatible with lung contusions. There is no
pleural effusion. Left lung is essentially clear. The tracheobronchial tree is
patent to the subsegmental level.
CT ABDOMEN WITH CONTRAST: There is a 5.6 x 3.1 x 9.3 cm intraparenchymal
contusion in the liver (series 602B image 21). There is small amount of
hemorrhage around the liver which tracks inferiorly along the paracolic gutter
into the pelvis. There is no intra or extrahepatic biliary duct dilation. The
gallbladder is normal.
6 mm hypodense peripheral focus in the upper aspect of the spleen may be a
small contusion. There is no perisplenic hemorrhage. The spleen, adrenal
glands, and kidneys are normal. Kidneys excrete contrast symmetrically without
hydronephrosis. The ureters are normal throughout their visualized course.
The stomach, small large bowel are normal in caliber without obstruction. The
abdominal aorta and iliac arteries are normal in caliber.
CT PELVIS WITH CONTRAST: The urinary bladder and rectum are normal. As
mentioned above hemorrhagic free fluid tracks into the right hemipelvis. Trace
amount of hemorrhage is also seen in the left hemipelvis.
BONES AND SOFT TISSUES: There is a nondisplaced fracture of the right seventh
rib laterally (series 2, image 35). There are fractures of the superior and
inferior left pubic rami. There also fractures of the left sacral ala and the
left ischial tuberosity (series 2, image 89). There are small anterior
fractures of the right and left pubic bones (2:109) at the pubic symphysis.
IMPRESSION:
1. Moderate right pneumothorax and pneumomediastinum. Multiple right lung
contusions. Nondisplaced right seventh rib fracture.
2. Grade two liver injury as detailed above. Small amount of perihepatic
hemorrhage tracking inferiorly into the pelvis.
3. Possible tiny contusion in the superior aspect of the spleen.
4. Fractures of the superior and inferior left pubic rami. Fractures of the
left sacral ale and left ischial tuberosity. Small anterior fractures of the
right and left pubic bones at the pubic symphysis
NOTIFICATION: Fracture of the pubic symphysis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p fall with rib frx, pneumothorax,
pneumomediastinum // Pls perform at 6 ___. please look for interval change in
pneumothorax/pneumomediastinum Pls perform at 6 ___. please look for
interval change in , pn
COMPARISON: Chest radiographs and chest CT performed between 11 and 11:45
today.
IMPRESSION:
Heterogeneous consolidation in the right lower lobe, new since earlier in the
day is local bleeding due to contusion and small laceration seen on the chest
CT scan. Followup advised.
Small right pneumothorax, confirmed by the chest CT scan, is most readily seen
along the right lower costal surface and is no larger now than it was earlier
in the day.
Small pneumomediastinum is unchanged. In the setting of closed chest trauma
this need not indicate disruption of the esophagus or tracheal bronchial tree,
either of which would probably produce more air in the mediastinum and
conceivably hemo mediastinal hematoma. Otherwise the cardiomediastinal
silhouette has a normal appearance. Left lung is clear and there is no left
pleural abnormality.
Detection of chest wall trauma is more reliable with torso CT.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo male s/p 30 ft fall with multiple injuries // assess for
interval changes. expiratory, sit up as much as possible assess for
interval changes. expiratory, sit up as much as p
COMPARISON: Chest radiographs on ___, read in conjunction with torso
CT also ___.
IMPRESSION:
The expiration view was obtained on the instructions of the requesting
physician. This may account for the apparent increase in size of the small
right pneumothorax which, in reality, may be unchanged. It may also
exaggerate the confluence of the previous consolidation in the right lower
lobe due to local bleeding. I have discussed the advisability of retaining of
obtaining full inspiratory chest radiographs hereafter.
Interval increase in heart size and mediastinal venous caliber is due in part
to lower lung volumes, but most likely increased intravascular volume as well.
Left lung is clear and there is no left pleural abnormality.
NOTIFICATION: Dr. ___ reported the findings to Dr ___ by telephone
on ___ at 10:44 AM, 5 minutes after discovery of the findings. The
explained that the patient has no findings to suggest continued bleeding in
the lung or pneumonia.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by HELICOPTER
Chief complaint: 30 FOOT FALL
Diagnosed with LIVER INJURY NOS, PELVIC FRACTURE NOS-CLOS, UNSPECIFIED FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient is a healthy ___ male who by report fell 30
feet through a sky light with GCS 15. He was brought to the
emergency department by med flight was concern for pelvic or hip
fracture. He complains of abdominal pain. Fast exam is negative.
CT demonstrates pneumothorax and right 7th rib fracture, lung
contusions. Imaging also reveal the patient has a left
compression pelvic fracture, and Orthopedic Surgery was
consulted. The patient was currently stable with a patent
airway and pain well controlled. Head CT and cervical spine CT
negative. CT abdomen demonstrates grade 2 liver laceration and
small splenic injury. Patient was admitted to ___ for further
management of injuries and serial hematocrits.
HD2 the patient was taken to the operating room with Orthopedics
for open reduction, internal fixation anterior pelvic ring and
posterior pelvic ring injury with 7.3 mm screws. The patient
tolerated the procedure well and remained hemodynamically
stable. On POD1 the patient was transferred to the floor.
Hematocrits remained stable. Pain was well controlled. Diet was
progressively advanced as tolerated to a regular diet with good
tolerability. The patient voided without problem. During this
hospitalization, the patient worked with Physical Therapy and
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with crutches, voiding without assistance, and
pain was well controlled. He was cleared by Physical Therapy
for home with outpatient ___. The patient was discharged home
without services. The patient and his family received discharge
teaching, including lovenox teaching with the use of an
interpreter, and follow-up instructions with understanding
verbalized and agreement with the discharge plan. He had
follow-up scheduled with the ___ clinic and with Orthopedics.
.. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
s/p ablation of atrial flutter ___
History of Present Illness:
___ with PMH HTN, COPD, and DMII p/w SOB. Pt woke up at 3am
gasping for breath and that is why she came in. She has had DOE
for many years now but this SOB was much worse and she "didn't
feel good." No CP but admits to a "tightening" sensation in the
___ her chest, which she can point to. Also admits to
lightheadedness with the SOB and also with the DOE that is
chronic. Cough has been worse recently and productive of more
sputum. No f/c/s, N/V/D, no dysuria. No blood in stool but stool
is "dark" after starting iron supplements. Denies ___ edema.
Denies orthopnea. Denies palpitations or syncope. Called EMS and
O2 sat was 92% so she was placed on O2 NC by EMT.
In the ED, initial VS 97.1, ___, 42, 98% 4L. And EKG
showed aflutter with RVR to 140s. No prior history of aflutter
or afib. Labs significant for Cr 1.5 (at baseline), negative
troponins, and Hct 34.3 (most recent baseline 33). CXR showed
"Moderate cardiomegaly, mild pulmonary edema and small bilateral
pleural effusions consistent with CHF." She was given aspirin
325, duonebs, diltiazem 10mg IV plus 30mg po for RVR. HR
improved to 100s and then to ___ prior to transfer.
On arrival to floor VS 97.3, 152/93, 115, 24, 90% RA. Pt has no
c/o currently.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
-HTN
-DM2
-Iron deficiency anemia
-Hypercholesterolemia
-Gout
-COPD with FEV1 42% of predicted in ___ (most recent testing)
-Obesity
-GI bleeding: ___ diverticular, ___ duodenal AVMs s/p cautery,
___ angioectasias of fundus s/p injections and thermal therapy
Social History:
___
Family History:
Father died of stroke at ___ years of age.
Mother died of diabetes complications in her ___.
___ brother had MI, 1 brother died of colon
cancer at ___
Physical Exam:
ADMISSION:
VS: 97.3, 152/93, 115, 24, 90% RA
General: morbidly obese female in NAD
HEENT: moist mucous membranes
Neck: no JVD
CV: faint heart sounds, RRR no m/r/g
Lungs: poor air movement bilaterally, no wheezes, rales, rhonchi
Abdomen: soft, NT, obese, NABS
Ext: 2+ pulses, no edema
Skin: warm and well-perfused
DISCHARGE:
VS: 98.3 (max 99.0) 145/72 (120s-150s/50s-70s) 80 (60s-90s)
20 94% RA (94-96% RA, 96-100% on 1.5-2L NC)
Weight: 100.2kg (I/O 145___ for 24hrs; 104/475 since MN)
Fasting blood sugar: 183 (FSBG on day prior: ___
General: No apparent distress
HEENT: EOMI, anicteric
Neck: +JVD in upright position
CV: RRR, no m/g/r
Pulm: No audible crackles bilaterally, no wheeze
Abd: +BS, soft, nontender, nondistended
Ext: Warm, right lower leg with mild pitting edema, no edema on
left. R groin with light purple patch in inguinal region. No
hematoma, no active bleeding, no bruit. Mildly tender to
palpation, improved. Right DP pulse 2+.
Neuro: Alert, nonfocal. R ankle flexion/extension intact.
Psych: Calm, appropriate
Pertinent Results:
ADMISSION LABS
___ 05:10AM ___ PTT-31.1 ___
___ 05:10AM PLT COUNT-295
___ 05:10AM NEUTS-78.5* LYMPHS-13.8* MONOS-5.4 EOS-1.7
BASOS-0.6
___ 05:10AM WBC-10.9 RBC-4.74 HGB-10.1* HCT-34.3* MCV-72*
MCH-21.3* MCHC-29.4* RDW-17.7*
___ 05:10AM cTropnT-<0.01
___ 05:10AM estGFR-Using this
___ 05:10AM GLUCOSE-216* UREA N-32* CREAT-1.5* SODIUM-143
POTASSIUM-5.2* CHLORIDE-103 TOTAL CO2-25 ANION GAP-20
___ 12:35PM URINE MUCOUS-RARE
___ 12:35PM URINE HYALINE-1*
___ 12:35PM URINE RBC-1 WBC-29* BACTERIA-MANY YEAST-NONE
EPI-<1
___ 12:35PM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 12:35PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 07:26PM TSH-2.3
___ 07:26PM CK-MB-2 cTropnT-<0.01
___ 07:26PM CK(CPK)-81
MICROBIOLOGY
Time Taken Not Noted Log-In Date/Time: ___ 6:02 pm
URINE TAKEN FROM 648B.
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
___ MORPHOLOGY.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
INTERIM LABS / LAB TRENDS
___ 05:10AM BLOOD cTropnT-<0.01
___ 07:26PM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS
___ 05:35AM BLOOD WBC-8.3 RBC-4.27 Hgb-9.0* Hct-30.4*
MCV-71* MCH-21.1* MCHC-29.6* RDW-18.3* Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD ___ PTT-99.7* ___
___ 05:35AM BLOOD Glucose-162* UreaN-29* Creat-1.4* Na-139
K-3.5 Cl-97 HCO3-30 AnGap-16
___ 05:35AM BLOOD Calcium-9.1 Phos-3.1 Mg-2.0
CXR PA/lateral ___
Thereis hyperinflation, consistent with background COPD. There
is increased
diffuse parenchymal opacities bilaterally, more prominent at the
bases
consistent with mild pulmonary edema. There are small bilateral
pleural
effusions layering posteriorly, left greater than right. There
is fluid in
the major fissure seen on the lateral view. There is moderate
cardiomegaly.
No pneumothorax. The left hemidiaphragm is elevated laterally.
IMPRESSION: Moderate cardiomegaly, mild pulmonary edema and
small bilateral
pleural effusions consistent with CHF.
TTE ___
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. There is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
mild-moderate pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis. Pulmonary artery hypertension. Mild symmetric left
ventricular hypertrophy with preserved regional and global
systolic function.
Compared with the prior study (images reviewed) of ___, the
right ventricular cavity dilation, free wall hypokinesis and
pulmonary artery hypertension are new.
This constellation of new findings is suggestive of an acute
pulmonary process (e.g., pulmonary embolism, etc.)
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
V/Q scan ___
INTERPRETATION: Both ventilation and perfusion images
demonstrate patchy
radiotracer activity, worse on the ventilation series, but
without areas of V/Q
mismatch. Soft tissue attenuation is seen in both the
ventilation and perfusion
images. No segmental defects are noted.
Chest x-ray shows moderate cardiomegaly, mild pulmonary edema,
and small
bilateral pleural effusions consistent with CHF.
IMPRESSION: Low likelihood ratio for acute pulmonary embolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral BID
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. MetFORMIN (Glucophage) 850 mg PO Frequency is Unknown
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Torsemide 5 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
9. Advair Diskus (fluticasone-salmeterol) Dose is Unknown
Unknown Inhalation daily
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Omeprazole 20 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH DAILY
5. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral BID
6. MetFORMIN (Glucophage) 850 mg PO Frequency is Unknown
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Torsemide 5 mg PO DAILY
9. Enoxaparin Sodium 100 mg SC Q 12 HRS Start: ___, First
Dose: Next Routine Administration Time
Please continue this medication until instructed to stop it by
your doctor.
RX *enoxaparin 100 mg/mL 100 mg SC q 12 hrs Disp #*14 Syringe
Refills:*0
10. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*200 Tablet
Refills:*0
11. Advair Diskus (fluticasone-salmeterol) 0 Unknown INHALATION
DAILY
12. Nystatin Cream 1 Appl TP BID
13. Outpatient Lab Work
Diagnosis: atrial flutter, ICD-9 427.32
Date of labs: ___
Send to: Dr. ___, ___ for nurse
___ ___
Lab to check: ___, INR, Na, K, Cl, bicarb, BUN, Cr, hemoglobin,
hematocrit
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: atrial flutter s/p ablation, decompensated diastolic
heart failure
Secondary: COPD, diabetes, hypertension, hyperlipidemia, history
of gastrointestinal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with cane.
Followup Instructions:
___
Radiology Report
INDICATION: Shortness of breath.
COMPARISON: Chest radiograph on ___.
FINDINGS: AP and lateral views of the chest.
Thereis hyperinflation, consistent with background COPD. There is increased
diffuse parenchymal opacities bilaterally, more prominent at the bases
consistent with mild pulmonary edema. There are small bilateral pleural
effusions layering posteriorly, left greater than right. There is fluid in
the major fissure seen on the lateral view. There is moderate cardiomegaly.
No pneumothorax. The left hemidiaphragm is elevated laterally.
IMPRESSION: Moderate cardiomegaly, mild pulmonary edema and small bilateral
pleural effusions consistent with CHF.
Gender: F
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with ATRIAL FLUTTER, CHRONIC AIRWAY OBSTRUCTION, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.1
heartrate: 149.0
resprate: 42.0
o2sat: 98.0
sbp: 171.0
dbp: 112.0
level of pain: nan
level of acuity: 1.0 | ___ with PMH HTN, COPD, and DMII p/w DOE of one day's duration
found to have new diagnosis of atrial flutter with e/o pulm
edema on CXR, now s/p ablation and diuresis.
ACTIVE DIAGNOSES
# Atrial flutter: Pt has severe COPD as well as diastolic heart
failure and UTI on admission, so these may be contributors to
atrial flutter. Hyperthyroidism was ruled out with normal TSH.
TTE showed new right ventricular cavity dilation, free wall
hypokinesis and pulmonary artery hypertension which were
concerning for acute PE, but V/Q scan showed low probability of
PE.
She was initially rate controlled with diltiazem and metoprolol.
Spontaneously converted to sinus rhythm just prior to TEE, so
TEE was cancelled prior to flutter ablation ___. Metoprolol
was continued post-procedure and diltiazem was stopped.
Management of diastolic heart failure exacerbation and UTI as
described below.
Anticoagulation was initially held given patient's history of GI
bleeding, but with a CHADS score of 4 she was started on
warfarin, bridging initially with heparin IV (TTE results were
concerning for possible PE, but V/Q scan was low probability for
PE so heparin gtt was changed to a-fib protocol). Heparin gtt
was replaced by Lovenox upon discharge. Anticoagulation should
be continued for at least one month post-ablation.
# Diastolic heart failure exacerbation: LVEF >/= 65% on TTE this
admission, consistent with diastolic dysfunction. Patient was
treated with IV furosemide with good response. Weight on
discharge was 100.2kg, with no crackles on exam. She was
returned to her home dose of torsemide 5mg daily upon discharge.
Check chemistry panel ___ for monitoring s/p treatment for
diastolic heart failure exacerbation.
# UTI: s/p three-day course of ciprofloxacin for Klebsiella UTI.
# Anemia: Pt has h/o iron deficiency anemia and GI bleeding (see
below). Hct was 34.3 on admission. Hct reached a minimum of
28.8 but was 30.5 on repeat check the same afternoon. Hct was
30.4 on day of discharge. Rectal exam produced no gross blood
and no gross stool (see below).
# Right groin irritation: skin of right inguinal region had
initially erythematous patch with gray film after ablation
procedure, which improved on post-procedure day 2. There was no
hematoma or bruit. Topical nystatin or Lotrimin was recommended
as necessary.
CHRONIC DIAGNOSES
# h/o GI bleeding: She had no evidence of active bleeding,
including no bowel movements for several days. Rectal exam ___
produced no gross stool or gross blood; guaiac was difficult to
interpret in the absence of a true sample but the glove was
guaiac negative. Attempted to advance bowel regimen on day of
discharge as pt had not produced any stool for sampling and
rectal exam had produced no significant sample, but pt declined
aggressive bowel regimen. Hct was stable this hospitalization
as described above. Continued omeprazole. Outpatient
colonoscopy ___.
# HTN: continued metoprolol as above.
# DM2: held metformin in house and replaced with sliding scale
insulin. Resumed home diabetes regimen upon discharge.
# Hypercholesterolemia: continued simvastatin.
# COPD: FEV1 of 42% of predicted in ___ (most recent
spirometry), reduced DLCO on outpatient testing with evidence of
emphysematous disease, outpt spirometry also shows restrictive
features thought secondary to obesity. Continued spiriva,
albuterol. Added ipratropium while hospitalized. Goal O2 sat
upper ___ - low ___. On day of discharge, O2 saturation went
down to 87-88% with ambulation while working with ___. Pt was
asymptomatic. Further monitoring/management as outpatient is
advised.
TRANSITIONAL ISSUES
*Check INR on ___ and titrate warfarin
accordingly. Stop Lovenox once INR >2.0. Warfarin can be stopped
1 month after ablation.
*Check chemistry panel ___ for monitoring s/p treatment for
diastolic heart failure exacerbation.
*O2 saturation went down to 87-88% with ambulation while working
with ___. Pt was asymptomatic. She has h/o COPD so slight
desaturation might be reasonable in her case. Further
monitoring/management as outpatient is advised.
*Colonoscopy on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R pilon fracture
Major Surgical or Invasive Procedure:
right pilon fracture ORIF ___
History of Present Illness:
Patient is a ___ right hand-dominant male, previously healthy who
presents w/ trimalleolar fracture s/p fall. Patient's mechanism
of injury was a fall down 25 feet from room while at work, onto
grass surface. Reports that he landed on right ankle and fell
onto right side w/ headstrike. Denies loss of conscioussness.
Was unable to ambulate due to pain.
Denies numbness, tingling weakness of tingling of ___. Denies any
loss of bowel or bladder tone. Has been NPO all day. Denied any
headache, visual changes, dizziness/lightheadedness. Denies
nausea, vomiting, chest pain, dyspnea, back pain or abdominal
pain. Went to ___ and was therein transferred
to ___ for operative fixation. He was hemodynamically stable
and neurovascular intact.
In the ED at the ___, initial vitals were 99.2 80 140/90 16
98%. Per the ED, the patient's exam did not suggest
neurovascular symptoms.
Patient has not prior history of injury or surgery to this
region.
Past Medical History:
___ GSWx3 (bilateral knees and left shoulder)
Social History:
___
Family History:
non contributory
Physical Exam:
VSS, afebrile
Gen - NAD
Cardiac - RRR
Pulm - no respiratory distress
Abd - soft, ___ - External fixator intact with dressings c/d/i, hardware in
good position
Pertinent Results:
___ 09:00PM GLUCOSE-89 UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
___ 09:00PM WBC-10.6 RBC-4.34* HGB-12.7* HCT-39.1* MCV-90
MCH-29.2 MCHC-32.5 RDW-12.4
___ 09:00PM NEUTS-81.6* LYMPHS-12.7* MONOS-5.4 EOS-0.1
BASOS-0.2
___ 09:00PM ___ PTT-32.0 ___
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ capsule(s) by mouth q4-6h Disp #*40
Capsule Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [___] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
5. Enoxaparin Sodium 30 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe im at bedtime Disp #*14
Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right pilon fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: External fixation of the right ankle in the OR.
Sixteen spot fluoroscopic views demonstrate the process of open reduction
internal fixation of complicated ankle fracture. Note is made that the
radiologist was not attending the procedure. For precise details, please
review procedure report.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX TRIMALLEOLAR-CLOSED, FALL FROM BUILDING
temperature: 99.2
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 140.0
dbp: 90.0
level of pain: 9
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right pilon fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for application of external fixator for R pilon fracture,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is nonweightbearing in the right
lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up on ___ to Dr.
___ with anticipated ORIF following. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
shortness of breath, submassive PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of BMI> 40,
remote provoked DVT/PE in ___ s/p 6mo warfarin, multiple
sclerosis, bilateral total knee arthroplasties and recent T2-T4
laminectomy for spinal stenosis (___) who presents with
progressive dyspnea on exertion.
She underwent thoracic laminectomies ~1 month ago, with 3 days
of immobility. Subsequently able to walk, and recently traveled
to ___ for one week, returning back to ___ 1 day prior to
admission (___). Flights were two 1.5hr flights as she had
a stopover in ___. She developed dyspnea on exertion,
which progressed over the weekend.
Using a friend's pulse oximeter, her SpO2 was low 80's/high90's,
whereas her normal SpO2 is 95-96% on room air, prompting her to
present to ___ ON ___.
There, she had a CTA with multiple PEs and c/f right heart
strain. She was transferred to ___ for consideration of lysis.
On the floor, she O2 sat in high ___ on 6L, so she was increased
to 10L on oxymizer. She reports still having dyspnea on
exertion, and feeling tired after walking to the bathroom with
oxymizer on.
She has had no recent leg or arm injury. She does report a
resolved L leg pain after surgery, prompting ultrasound at ___
___ ___ which showed no DVT.
She reports significant family history of cancer, brother with
leukemia age ___, sister with ?stomach cancer died age ___, sister
with breast cancer age ___. She had negative mammography and L
breast ultrasound ___. Last pap smear ___ yr ago, normal.
Last colonscopy ___ yr ago, normal.
Of note, during ___ admission for laminectomy, she had
increased O2 requirement difficult to wean after surgery. ___
CTA chest was performed and called "Severely limited examination
due to respiratory motion artifact. Within these limitations,
no large central pulmonary embolism," and showed pulmonary
artery hypertension. Medicine was consulted and though more
likely d/t obesity, recent surgery, and known OSA, and should
improve with rehab and mobilization. She was weaned off oxygen,
bridged from enoxaparin to warfarin, and discharged.
Past Medical History:
Dyslipidemia
PE (___)
OSA w/ CPAP
Multiple sclerosis
Right side trigeminal neuralgia
Obesity
S/p bilateral total knee replacements
S/p C-section ___
S/p Bunionectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.0 HR 76 BP 119/80 SpO2 91%on 6L nc
GEN: well-appearing woman sitting upright in bed with oxymizer
on, in NAD.
HEENT: NCAT, PERRL, EOMI, MMM
NECK: unable to assess JVP d/t adipose tissue
CV: nl rate, reg rhythm, nl S1, S2.
RESP: distant BS though clear bilaterally, no crackles or
wheezes
GI: ND, NT
MSK: warm, b/l knee scars, legs w/o erythema or edema, no TTP.
SKIN: no rashes
NEURO: AAOx3, conversant, face symmetric, moves all 4 w purpose
DISCHARGE PHYSICAL EXAM:
========================
PHYSICAL EXAM:
VITALS: Temp: 97.6 PO BP: 159/87 HR: 59 RR: 18 O2 sat: 93% O2
delivery: Ra
GENERAL: Well-appearing woman, in NAD
HEENT: NC/AT, EOMI, MMM
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB, breathing comfortably on RA without use of
accessory muscles, no wheezes or crackles
ABDOMEN: Soft, nontender, nondistended, active bowel sounds
EXTREMITIES: No c/c/e
SKIN: Warm, well-perfused, no rashes
NEUROLOGIC: Alert, moving all extremities with purpose, no
facial asymmetry
Pertinent Results:
ADMISSION LABS:
===============
___ 08:14PM BLOOD WBC-6.0 RBC-3.74* Hgb-11.6 Hct-36.4
MCV-97 MCH-31.0 MCHC-31.9* RDW-14.8 RDWSD-50.1* Plt ___
___ 08:14PM BLOOD Neuts-62.6 ___ Monos-7.5 Eos-3.3
Baso-0.5 Im ___ AbsNeut-3.74 AbsLymp-1.54 AbsMono-0.45
AbsEos-0.20 AbsBaso-0.03
___ 08:14PM BLOOD ___ PTT-150* ___
___ 08:14PM BLOOD Glucose-111* UreaN-18 Creat-0.8 Na-142
K-4.1 Cl-103 HCO3-24 AnGap-15
___ 08:14PM BLOOD proBNP-159
___ 08:14PM BLOOD cTropnT-0.11*
___ 08:20PM BLOOD ___ pO2-59* pCO2-36 pH-7.46*
calTCO2-26 Base XS-1
___ 08:20PM BLOOD Lactate-2.1*
PERTINENT LABS:
================
___ 08:14PM BLOOD cTropnT-0.11*
___ 04:46AM BLOOD cTropnT-0.04*
___ 08:14PM BLOOD proBNP-159
___ 08:20PM BLOOD ___ pO2-59* pCO2-36 pH-7.46*
calTCO2-26 Base XS-1
___ 08:20PM BLOOD Lactate-2.1*
___ 04:59AM BLOOD Lactate-1.1
___ 05:56AM BLOOD ___ PTT-36.6* ___
___ 06:10AM BLOOD ___
___ 06:30AM BLOOD ___
___ 06:27AM BLOOD ___
___ 06:00AM BLOOD ___ PTT-33.0 ___
PERTINENT IMAGING:
==================
___ CT Angiogram Chest for PE (at ___
1. Extensive, acute, pulmonary arterial embolic burden
bilaterally, as described.
2. Moderately enlarged main pulmonary artery and minimal bowing
of the interventricular septum toward the left ventricle,
suggesting pulmonary arterial hypertension and very early right
heart strain, respectively.
3. Atherosclerosis.
4. Hepatic steatosis.
___ CXR
The cardiopericardial silhouette is borderline enlarged. The
aorta is unremarkable. The lungs are well expanded and clear.
The
costophrenic angles are sharp. There is no pneumothorax
___ ___ (at ___
No evidence of DVT on the left.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Calcium Carbonate 1500 mg PO DAILY
4. Carbamazepine (Extended-Release) 400 mg PO BID
5. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK
6. Hydrochlorothiazide 25 mg PO DAILY
7. Simvastatin 40 mg PO QPM
8. Vitamin D 5000 UNIT PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
11. Docusate Sodium 100 mg PO BID
12. Heparin 5000 UNIT SC BID
13. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line
14. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 110 mg SC Q12H
RX *enoxaparin 120 mg/0.8 mL 110 mg SC once a day Disp #*15
Syringe Refills:*0
2. Warfarin 1 mg PO DAILY16
Please take 5mg on ___. Subsequent dosing TBD by PCP.
RX *warfarin 1 mg 1 tablet(s) by mouth once a day Disp #*150
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Aspirin 81 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
7. Calcium Carbonate 1500 mg PO DAILY
8. Carbamazepine (Extended-Release) 400 mg PO BID
9. Copaxone (glatiramer) 40 mg/mL subcutaneous 3X/WEEK
10. Docusate Sodium 100 mg PO BID
11. Hydrochlorothiazide 25 mg PO DAILY
12. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second
Line
13. Polyethylene Glycol 17 g PO DAILY
14. Simvastatin 40 mg PO QPM
15. Vitamin D 5000 UNIT PO DAILY
16.Outpatient Lab Work
Labs: INR to be drawn on ___
ICD code: ___
Fax results to: Dr. ___ at ___
___, fax ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
====================
Submassive pulmonary embolism
Acute hypoxic respiratory failure
SECONDARY DIAGNOSIS:
=======================
Obesity
History of DVT/PE
Spinal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with PE// rule out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow
demonstrated in the posterior tibial and peroneal veins. Grayscale images the
calf veins were limited due to body habitus and soft tissue edema.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale, Dyspnea, unspecified
temperature: 97.8
heartrate: 76.0
resprate: 24.0
o2sat: 98.0
sbp: 142.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
___ hx of obesity, provoked DVT/PE in ___ and recent T2-T4
laminectomy for spinal stenosis (___) who initially
prsented with dyspnea, found to have submassive PE, s/p heparin
gtt, then transitioned to warfarin (on ___ bridge), with
subtherapeutic INR on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gluten / Gentamicin
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year-old gentleman with history of
HFrEF(iCMP, EF 31%), MDS and relapsed high-grade ___ lymphoma
with Burkitt-like features, last treated with R-EPOCH (___) presenting following a fall with headstrike found to be
neutropenic with low grade temperatures.
Per report Mr. ___ was in his usual state of health until
this morning when he walked to the bathroom wearing loose socks.
His daughter heard a thud on the floor and found him conscious
with epistaxis which resolved with pressure. A small laceration
in the bridge of the nose was noted as well as an abrasion in
the left shin. He was seen in ___ clinic this morning where he
did not recall tripping on anything. He reported having frequent
bowel movements upon discharge a couple of days ago which
improved. In clinic he had a temperature to 99.5F and was sent
in to ED for further work-up, initiation of IV antibiotics and
admission.
ED initial vitals were 98.6 84 121/63 19 100% RA
Prior to transfer vitals were 98.4 94 110/64 17 98% RA
Exam in the ED showed : "1 cm abrasion/laceration to the bridge
of this nose. No hemotympanum. No septal hematoma. 8 cm abrasion
to the left anterior shin. skin tear with xeroform on left
anterior shin."
ED work-up significant for:
-CBC: WBC: 0.4*. HGB: 8.0*. Plt Count: 82*. Neuts%: 70
-Chemistry: Na: 142 . K: 4.3 . BUN: 23*. Creat: 1.1. Ca: 8.5.
Mg:
1.7. PO4: 2.0*.
-Lactate: 2.5
-LFTs: ALT: 12. AST: 15. Alk Phos: 109. Total Bili: 0.7.
-UA: RBC 1, WBC 1
-CT head/neck: No acute intracranial process or C-spine fracture
ED management significant for:
-Medications: Vancomycin 1g, Cefepime 2g
-Procedures: Nasal bridge abrasion closed with dermabond
On arrival to the floor, patient reports that his fall was
purely mechanical by slipping on oversized sock. He reports
recalling the whole event and not having any
syncopal/presyncopal symptoms.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss,
shortness of breath, cough, hemoptysis, chest pain,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
Past Medical History:
- Type II diabetes mellitus
- HLD
- Hypertension
- CAD status post CABG (___)
- VT ablation ___
- HFrEF
- MDS
- Zoster esophagitis
- Vestibular nerve damage secondary to gentamicin
- BPH status post laser surgery
- Spinal stenosis status post laminectomy in ___
- Celiac disease
- Small bowel perforation status post resection and repair with
CMV inclusion bodies on the bowel biopsy after two cycles of
R-CHOP
Social History:
___
Family History:
Son was diagnosed with thyroid cancer at age ___, doing well now.
Brother with prostate cancer. No other known cancers in the
family. Mother died of an MI in ___. Father also had diabetes,
died of unknown cause in ___.
Physical Exam:
ADMISSION EXAM
============================
VS: ___ Temp: 98.9 PO BP: 111/65 L Sitting HR: 95 RR:
18 O2 sat: 98% O2 delivery: RA
GENERAL: Well- appearing gentleman in no distress sitting in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to
light touch intact.
SKIN: small abrasion in bridge of nose and ___ fold,
2x2cm well-healing erosion in dorsum of L foot w/o erythema or
secretion, 1x1cm similar in dorsum of R foot, 1x2cm similar in
back of left foot. New left shin erosions with significant
serous
drainage covered with damp gauze.
DISCHARGE EXAM
============================
VITALS: 98.4 104 / 69 92 18 95 Ra
GENERAL: Older appearing man, comfortable, lying in bed
NEURO: Oriented to location, month, year. Moving all four
extremities, follows commands. Pupils equal and reactive
bilaterally.
HEENT: Mild abrasion over nasal bridge. No JVD
CARDIAC: Very distant heart sounds, RRR, no murmurs
PULMONARY: Decreased breath sounds bilaterally at the bases
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: 1+ pitting edema bilaterally, both feet are wwp
SKIN: No significant rashes but abrasions on shins and right
dorsal foot
Pertinent Results:
ADMISSION LABS ___:
============================
WBC-0.4* RBC-2.71* Hgb-8.0* Hct-26.0* MCV-96 MCH-29.5 MCHC-30.8*
RDW-15.8* RDWSD-54.3* Plt Ct-82*
Neuts-70 Bands-0 ___ Monos-4* Eos-1 Baso-0 ___ Metas-0
Myelos-0 AbsNeut-0.28* AbsLymp-0.10* AbsMono-0.02* AbsEos-0.00*
AbsBaso-0.00*
___ PTT-26.8 ___
UreaN-23* Creat-1.1 Na-142 K-4.3
ALT-12 AST-15 LD(LDH)-180 AlkPhos-109 TotBili-0.7
Albumin-3.2* Calcium-8.5 Phos-2.0* Mg-1.7 UricAcd-5.7
BLOOD Lactate-2.5*
URINE Color-Yellow Appear-Clear Sp ___
URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
PERTINENT LABS
============================
___ tTG-IgA-5 antiDGP-1
___ cTropnT-0.03*
___ cTropnT-0.03*
___ CK-MB-1 cTropnT-0.01
___ Hapto-345*
___ TSH-2.0
___ ___
___ Ret Aut-3.1* Abs Ret-0.08
___ calTIBC-143* ___ Hapto-352* Ferritn-2636*
TRF-110*
___ %HbA1c-6.5* eAG-140*
___ Triglyc-199* HDL-24* CHOL/HD-5.4 LDLcalc-66
___ CK-MB-<1 cTropnT-0.06* ___
___ cTropnT-0.05*
DISCHARGE LABS ___:
============================
WBC-9.1 RBC-2.85* Hgb-8.1* Hct-25.9* MCV-91 MCH-28.4 MCHC-31.3*
RDW-19.3* RDWSD-63.3* Plt ___
Glucose-87 UreaN-20 Creat-1.1 Na-144 K-4.6 Cl-103 HCO3-28
AnGap-13
Calcium-8.5 Phos-3.2 Mg-2.2
PERTINENT MICRO
============================
ALL BLOOD AND URINE CULTURES WITH NO GROWTH TO DATE
___ 4:15 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
PERTINENT STUDIES
============================
CT HEAD (___)
No acute intracranial process.
CT C-SPINE (___)
No fracture is identified.
CT HEAD (___)
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no
evidence of intracranial hemorrhage or acute large territory
infarct.
2. Additional findings described above.
CXR (___)
Heart size is enlarged. Hiatal hernia is large. There is mild
vascular
congestion. There is no appreciable pleural effusion. There is
no
pneumothorax.
CXR (___)
There is a new right-sided PICC line with distal tip at the
cavoatrial
junction. Heart size is prominent but stable. Opacity along
the right heart
border is due to a very large hiatal hernia. There are no
pneumothoraces.
CXR (___)
Right PIC line ends in the right atriumd approximately 3 cm
below the
estimated location of the superior cavoatrial junction.
Small to moderate right pleural effusion and large
gastrointestinal hiatus
hernia projecting to the right of midline, are long-standing.
The hernia
exaggerates the size of mildly to moderately enlarged heart.
Upper lungs are
clear. There is pulmonary edema and no pneumothorax.
CXR (___)
Bilateral lower lobe collapse unchanged. Small right pleural
effusion
decreased. No pneumothorax. Mild cardiomegaly stable. No
pulmonary edema or mediastinal widening. Right PICC line ends in
the upper right atrium as before.
CT HEAD (___)
Atrophy.
No significant changes since ___.
No evidence of hemorrhage.
RENAL US (___)
No hydronephrosis.
ECHO (___)
IMPRESSION: Suboptimal image quality. Left ventricular cavity
enlargement with regional and global systolic dysfunction
suggestive of multivessel CAD or other diffuse process. Mild
aortic regurgitation.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation is reduced (may be due to
technical quality rather than a true change).
CT CHEST (___)
-Bilateral small layering pleural effusions are larger since
prior, right
greater the left. Adjacent consolidations, left greater than
right are likely due to aspirations, particularly in the
presence of large hiatal hernia.
-Increased fat stranding surrounding the partially imaged left
kidney could
represent infection, for clinical correlation.
CXR (___)
There is bilateral lower lobe atelectasis, similar to previous.
Superimposed pneumonia cannot be excluded. There is pulmonary
vascular congestion. There is a small right pleural effusion,
not significantly changed. There may be a trace left effusion.
There is mild cardiomegaly, similar to previous. The tip of the
right PICC appears stable in position. Sternal wires appear
intact.
CXR (___)
1. Interval increase in bilateral interstitial opacities,
consistent with
worsening pulmonary edema.
2. Focal increase in opacification at the right lower lobe,
which may
represent superimposed infection, aspiration, or asymmetric
edema.
3. Small bilateral pleural effusions, right greater than left.
CT ABD/PELVIS (___)
1. Stable mild stranding involving the omentum on the right
complete similar to the CT findings from ___. Mild increased perinephric stranding on the left, no evidence
of
hydronephrosis. Recommend clinical correlation to exclude
underlying
infection.
3. No other interval change.
CT CHEST (___)
1. No evidence of lymphadenopathy.
2. Stable airspace opacification in the left lower lobe
suggestive of
consolidation. New small scattered areas of ground-glass
opacities in the
right upper and middle ___ represent infectious etiology.
Clinical
correlation recommended.
3. Mild interval increase in bilateral pleural effusions which
are moderate. Stable bibasilar passive atelectasis.
MRI HEAD (___)
Multiple (approximately 7) bilateral punctate supra and infra
tentorial acute infarct. These are most likely embolic in
nature. No hemorrhagic
transformation. No intracranial hemorrhage or mass. Generalized
cerebral atrophy with white matter microangiopathic changes.
CXR (___)
A new right PICC line projects over the mid SVC. Bilateral
pleural effusions with subjacent atelectasis/consolidation.
CTA HEAD/NECK (___)
The study is degraded by incorrect bolus timing and motion
artifact.
No acute hemorrhage or large territorial infarct.
Known bilateral punctate supra and infratentorial acute
infarctions are better appreciated on prior MRI head done ___. These infarcts are most likely embolic in nature. Within
the limits of the study there is no intracranial arterial
aneurysm or occlusion. No ICA occlusion. No obvious ICA
stenosis by NASCET criteria. Increased soft tissues surrounding
the junction of V3 and V4 segment of the right vertebral artery
may be secondary to accompanying veins or may represent
dissection, these cannot be differentiated due to poor contrast
bolus timing and repeat CTA is advised.
CXR (___)
Comparison to ___. Stable low lung volumes. Stable
bilateral pleural effusions of moderate extent. Stable
subsequent bilateral areas of
atelectasis. Today's radiograph shows signs of mild pulmonary
edema.
Unchanged alignment of the sternal wires. Unchanged right PICC
line.
BEDSIDE ECHO (___)
There is moderate-severe regional left ventricular systolic
dysfunction with severe hypokinesis/ akinesis of the basal to
mid inferoseptum, inferior, and inferolateral walls and the
distal inferior wall (see
schematic) and severe global hypokinesis of the remaining
segments. The visually estimated left ventricular ejection
fraction is ___. Mildly dilated right ventricular cavity with
mild global free wall
hypokinesis. There is mild [1+] aortic regurgitation. There is
mild [1+] mitral regurgitation.
IMPRESSION: Adequate image quality. Compared with the prior TTE
of (images reviewed) of ___ , the findings are similar
(right ventricle also appeared borderline/ mildly dilated).
LEFT VENTRICLE (LV) Visual Ejection Fraction: ___ (nl
M:52-72;F:54-74)
LEFT VENTRICLE (LV): Moderate-severe focal systolic dysfunction.
The visually estimated left ventricular ejection fraction is
___.
RIGHT VENTRICLE (RV): Dilated cavity. Mild global free wall
hypokinesis.
AORTIC VALVE (AV): Mild [1+] regurgitation.
MITRAL VALVE (MV): Mild [1+] regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atovaquone Suspension 1500 mg PO DAILY PCP ___
2. Filgrastim-sndz 480 mcg SC Q24H
3. Doxycycline Hyclate 100 mg PO Q12H
4. Acyclovir 400 mg PO Q12H
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Levofloxacin 500 mg PO Q24H
8. Ranitidine 150 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
12. LORazepam 0.5 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Apixaban 5 mg PO BID
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
4. Docusate Sodium 100 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Acyclovir 400 mg PO Q12H
10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
11. Ranitidine 150 mg PO BID
12. Senna 8.6 mg PO BID:PRN constipation
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
-------------------
___ lymphoma with Burkitt's features
Sepsis
Neutropenic Fever
Embolic cerebral vascular accidents
Acute on chronic systolic heart failure
Ischemic cardiomyopathy
Coronary artery disease status post coronary artery bypass graft
Atrial fibrillation, new
SECONDARY:
-------------------
Type II NSTEMI
Toxic metabolic encephalopathy
Normocytic anemia
Acute kidney injury
Acute urinary retention
Benign prostatic hypertrophy
Ureteral stricture
Mechanical fall
Diarrhea
Oropharyngeal candidiasis
Celiac disease
Type II Diabetes
Gastroesophageal reflux disease
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall with head strike// evaluate for intra-cranial
bleed, fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 22.1 mGy (Body) DLP =
362.1 mGy-cm.
Total DLP (Body) = 362 mGy-cm.
COMPARISON: CT head without contrast ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall with head strike// evaluate for intra-cranial
bleed, fracture evaluate for intra-cranial bleed, fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed through the
cervical spine. Soft tissue and bone algorithm images were generated.
Coronal and sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.5 s, 21.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 493.4
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 15.0 mGy (Body) DLP =
30.0 mGy-cm.
Total DLP (Body) = 553 mGy-cm.
COMPARISON: None.
FINDINGS:
No traumatic malalignment is identified.No fractures are identified.There is
no prevertebral soft tissue swelling.
Mild posterior narrowing of disc space at C3-4 and C4-5 are likely
degenerative. Severe degenerative changes of the cervical spine is notable for
endplate and uncovertebral joint osteophytes causing severe neural foraminal
narrowing on the right side at C5-6.
IMPRESSION:
No fracture is identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with thrombocytopenia and acute altered mental status//
intracranial bleed?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.0 s, 20.5 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,068.6 mGy-cm.
Total DLP (Head) = 1,069 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass effect. There is prominence of the ventricles and sulci suggestive of
involutional changes. Periventricular and subcortical white matter
hypodensities are nonspecific, but likely reflect sequelae of chronic small
vessel ischemic disease.
Nasal bone fracture deformities are unchanged from prior exam. There is no
evidence of acute fracture. The visualized portion of the paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The visualized portion
of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT. Specifically no
evidence of intracranial hemorrhage or acute large territory infarct.
2. Additional findings described above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with heart failure// pulmonary edema? pulmonary edema?
IMPRESSION:
Heart size is enlarged. Hiatal hernia is large. There is mild vascular
congestion. There is no appreciable pleural effusion. There is no
pneumothorax.
Radiology Report
INDICATION: ___ year old man with new R PICC 45cm// new R PICC ___
Contact name: ___: ___
COMPARISON: ___
IMPRESSION:
There is a new right-sided PICC line with distal tip at the cavoatrial
junction. Heart size is prominent but stable. Opacity along the right heart
border is due to a very large hiatal hernia. There are no pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with chronic afib with rates 90-120 w/bursts to
160 that are HD stable now w/ new hypoxia, possibly from over volume
resuscitation// degree of pulm edema, effusions, if worsened cardiomegaly,
please comment on PICC if think needs to be pulled back given concern if
irritating atria degree of pulm edema, effusions, if worsened cardiomegaly,
please comment on PICC if think needs to be pulled back given concern if
irritating atria
IMPRESSION:
Compared to chest radiographs ___ through ___.
Right PIC line ends in the right atriumd approximately 3 cm below the
estimated location of the superior cavoatrial junction.
Small to moderate right pleural effusion and large gastrointestinal hiatus
hernia projecting to the right of midline, are long-standing. The hernia
exaggerates the size of mildly to moderately enlarged heart. Upper lungs are
clear. There is pulmonary edema and no pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ cough and dyspnea// pneumonia? pneumonia?
IMPRESSION:
Compared to chest radiographs ___ through ___.
Bilateral lower lobe collapse unchanged. Small right pleural effusion
decreased. No pneumothorax. Mild cardiomegaly stable. No pulmonary edema or
mediastinal widening.
Right PIC line ends in the upper right atrium as before.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ w/ severe thrombocytopenia and altered mental status//
intracranial hemorrhage?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.5 s, 21.5 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,120.5 mGy-cm.
Total DLP (Head) = 1,121 mGy-cm.
COMPARISON: Head CT ___.
FINDINGS:
There been no significant changes since the prior study. There is no evidence
of infarction, hemorrhage, edema, or mass. The ventricles and sulci are
enlarged in an atrophic pattern.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Atrophy.
No significant changes since ___.
No evidence of hemorrhage.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ w/ relapsed lymphoma and ___// hydronephrosis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: ___.
FINDINGS:
The right kidney measures 8.9 cm. The left kidney measures 10.8 cm. Evaluation
of the renal parenchyma is limited due to poor penetration and difficulty
positioning the patient. Within these limitations, there is no hydronephrosis
or shadowing calculi.
The bladder is moderately well distended and unremarkable.
IMPRESSION:
No hydronephrosis.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ w/ B-cell lymphoma, heart failure with dyspnea and cough//
pulm edema and/or pneumonia?
TECHNIQUE: Multi detector helical scanning of the chest was reconstructed as
5 and 1.0 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. No contrast agent was administered. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.0 s, 37.2 cm; CTDIvol = 11.3 mGy (Body) DLP = 421.6
mGy-cm.
Total DLP (Body) = 422 mGy-cm.
COMPARISON: CT of the chest ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: No pathologic enlargement of lymph
nodes in the supraclavicular or axillary stations. There is new mild diffuse
chest wall edema which is more pronounced at the level of the flanks.
CHEST CAGE: Minimal degenerative changes at the level of the thoracic
vertebra. L1 severe wedge compression fracture is mildly more sclerotic in
comparison to ___. There is no evidence of lytic or sclerotic
metastatic osseous destructive lesions the level of the ribs, sternum or
vertebra.
UPPER ABDOMEN: There is relative atrophy of the partially imaged right kidney
which is stable. Increased fat stranding surrounding the left kidney is
nonspecific, for clinical correlation since could represent infection.
Remaining unenhanced upper abdominal organs are with no gross findings.
MEDIASTINUM: Almost the entire stomach included a in large hiatal hernia,
unchanged since prior and upper esophagus is patulous as before. There is no
lymphadenopathy in the mediastinum and hilar silhouettes suggest no gross
lymphadenopathy.
HEART and PERICARDIUM: Heart is normal in size. There are signs of mild
anemia. Patient is status post sternotomy and CABG, there are extensive dense
calcifications of native coronaries. There is no pericardial effusion.
Minimal calcifications along the normal caliber thoracic aorta, main
pulmonary artery is normal in caliber.
PLEURA and LUNG: Bilateral small layering pleural effusions are larger since
prior, right greater the left. Adjacent consolidations containing air
bronchograms reflect pneumonia, particularly in the left lower lobe (4:149),
possibly due to aspirations, particularly in the presence of large hiatal
hernia.
Tracheobronchial tree is centrally patent.
In the right upper lobe linear scar-like opacity with linear pleural tag is
unchanged since ___ (4:109). No new pulmonary nodules.
IMPRESSION:
-Bilateral small layering pleural effusions are larger since prior, right
greater the left. Adjacent consolidations, left greater than right are likely
due to aspirations, particularly in the presence of large hiatal hernia.
-Increased fat stranding surrounding the partially imaged left kidney could
represent infection, for clinical correlation.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ w/ B-cell lymphoma, a-fib w/ new dysphagia// mass lesion or
evidence of CVA?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CT brain done ___
FINDINGS:
Multiple (approximately 7) bilateral punctate supra and infratentorial acute
infarcts. No hemorrhagic transformation. Generalized cerebral atrophy with
ex vacuo dilatation of the ventricular system. Moderate periventricular deep
white matter T2 and FLAIR hyperintense changes are most likely sequela of
microangiopathy. There is no abnormal enhancement after contrast
administration. The orbits appear normal. Mild mucosal thickening involving
the paranasal sinuses. The intracranial arteries demonstrate normal T2 flow
voids. The pituitary appears normal. The craniocervical junction appears
normal.
IMPRESSION:
Multiple (approximately 7) bilateral punctate supra and infra tentorial acute
infarct. These are most likely embolic in nature. No hemorrhagic
transformation.
No intracranial hemorrhage or mass.
Generalized cerebral atrophy with white matter microangiopathic changes.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:25 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ with AML with worsening cough// pneumonia?
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray 438
FINDINGS:
There is bilateral lower lobe atelectasis, similar to previous. Superimposed
pneumonia cannot be excluded. There is pulmonary vascular congestion. There
is a small right pleural effusion, not significantly changed. There may be a
trace left effusion. There is mild cardiomegaly, similar to previous. The
tip of the right PICC appears stable in position. Sternal wires appear
intact.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ w/ B-cell lymphoma, CHF with worsening cough. Evaluation for
pulm edema vs. worsening pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison to radiograph from ___. Comparison to CT chest from ___.
FINDINGS:
Median sternotomy wires are intact and well aligned. Right sided PICC line
appears to end at the low SVC. Cardiomediastinal silhouette is stable.
Interval increase in bilateral interstitial opacities is consistent with
worsening pulmonary edema. Focal increase in opacification at the right lower
lobe may represent pneumonia or aspiration. There are small bilateral pleural
effusions, right greater than left. No pneumothorax is seen.
IMPRESSION:
1. Interval increase in bilateral interstitial opacities, consistent with
worsening pulmonary edema.
2. Focal increase in opacification at the right lower lobe, which may
represent superimposed infection, aspiration, or asymmetric edema.
3. Small bilateral pleural effusions, right greater than left.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ w/ history B-cell lymphoma s/p recent EPOCH// repeat staging/
response to chemotherapy?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis without intravenous contrast.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.3 s, 66.9 cm; CTDIvol = 12.2 mGy (Body) DLP =
809.6 mGy-cm.
Total DLP (Body) = 810 mGy-cm.
COMPARISON: ___
FINDINGS:
Please note that the images are degraded by motion artifact.
Liver: Liver demonstrates normal parenchymal morphology. No focal lesions
given limitations of an unenhanced study.
Biliary: The gallbladder is normally distended. No intra or extrahepatic
biliary dilatation.
Pancreas: Pancreas shows homogeneous signal intensity. No evidence of
pancreatic ductal dilatation.
Spleen: Normal size without evidence of focal lesions.
Adrenal Glands: Normal size bilaterally.
Kidneys: Stable atrophic right kidney. No evidence of nephrolithiasis. There
is mild perinephric stranding surrounding the left kidney, which is new
compared to the prior CT from ___. There is no hydronephrosis.
Gastrointestinal Tract: Large hiatus hernia containing almost entire stomach
filled with oral contrast. The small and large bowel loops are normal in
caliber. Trace free fluid seen in the abdomen. There is minimal residual
stranding in the omentum in the right (series 2, image 77), similar to the
findings on the prior CT from ___.
Lymph Nodes: No retroperitoneal or mesenteric lymphadenopathy.
Pelvis: Urinary bladder is decompressed and shows Foley bulb in situ.
Vascular: Moderate aortic atherosclerotic changes. Stable aneurysmal
dilatation of the left common iliac artery measuring 2.4 cm.
Osseous and Soft Tissue Structures: Stable significant compression fracture
involving L1 vertebral body with buckling of the posterior coursed cortex
causing spinal canal stenosis at this level. Multilevel degenerative disc
disease. No new abnormality identified.
IMPRESSION:
1. Stable mild stranding involving the omentum on the right complete similar
to the CT findings from ___. Mild increased perinephric stranding on the left, no evidence of
hydronephrosis. Recommend clinical correlation to exclude underlying
infection.
3. No other interval change.
Radiology Report
EXAMINATION: Noncontrast CT chest
INDICATION: ___ male with history of B-cell lymphoma, status post
recent EPOCH, repeat staging, response to chemotherapy.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Recent CT chest from 3 days ago (___).
FINDINGS:
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
HEART AND VASCULATURE: Right upper extremity PICC seen with its tip in
proximal right atrium. The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits based on an unenhanced
scan. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present.
PLEURAL SPACES: Moderate pleural effusions bilaterally with minimal increase
in the amount compared to the recent prior CT..
LUNGS/AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally. Again seen is evidence of airspace opacification involving the
left lower lobe. There are few new scattered areas of ground-glass opacities
for example in the right upper lobe (series 3, image 93, right middle lobe
(series 3, image 166 and 188). Stable appearance of bilateral subsegmental
passive atelectasis in both lower lobes.
ABDOMEN: Large hiatus hernia with stomach filled with oral contrast seen above
the diaphragmatic hiatus. Please refer to the separately dictated report of
CT abdomen and pelvis.
BONES: Stable significant wedge compression fracture involving L1 vertebral
body with more than 75% vertebral body height loss and buckling of the
posterior cortex. Stable appearance of the median sternotomy wires in situ.
IMPRESSION:
Compared to 3 days prior:
1. No evidence of lymphadenopathy.
2. Stable airspace opacification in the left lower lobe suggestive of
consolidation. New small scattered areas of ground-glass opacities in the
right upper and middle ___ represent infectious etiology. Clinical
correlation recommended.
3. Mild interval increase in bilateral pleural effusions which are moderate.
Stable bibasilar passive atelectasis.
Radiology Report
INDICATION: ___ s/p prior PICC placement// re-assessment of PICC location
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ CT chest
FINDINGS:
There are bilateral pleural effusions with subjacent atelectasis and/or
consolidation. A hiatal hernia is again noted. The size of the cardiac
silhouette is enlarged but unchanged. The tip of a right PICC line projects
over the mid SVC. No pneumothorax.
IMPRESSION:
A new right PICC line projects over the mid SVC.
Bilateral pleural effusions with subjacent atelectasis/consolidation.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ w/ a-fib and newly diagnosed embolic infarcts// rule out
vascular etiology for acute infarcts
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9
mGy-cm.
3) Stationary Acquisition 1.4 s, 0.2 cm; CTDIvol = 21.9 mGy (Head) DLP =
4.4 mGy-cm.
4) Spiral Acquisition 6.2 s, 40.1 cm; CTDIvol = 32.7 mGy (Head) DLP =
1,289.3 mGy-cm.
Total DLP (Head) = 2,152 mGy-cm.
COMPARISON: Prior brain MR done ___
FINDINGS:
The study is degraded by incorrect bolus timing and motion artifact.
CT HEAD WITHOUT CONTRAST:
There is no evidence of hemorrhage. Known, bilateral, punctate super and
infratentorial acute infarctions are better appreciated MRI head from ___ at 07:55. Generalized cerebral atrophy with ex vacuo dilatation of the
ventricular system.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
Within the limits of the study there is no intracranial arterial aneurysm or
arterial occlusion.
CTA NECK:
Within the limits of the study there is no carotid arterial occlusion or
aneurysm. No obvious ICA stenosis by NASCET criteria. Increased soft tissues
surrounding the junction of V3 and V4 of the right vertebral artery, poorly
characterized, may be secondary to accompanying veins or may represent
dissection, these cannot be differentiated due to poor contrast bolus timing
and repeat CT or correlation with an MR study is advised. The left vertebral
artery appears patent.
OTHER:
Patulous esophagus. Bilateral pleural effusions and interstitial thickening
most likely representing pulmonary edema. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Evidence of prior CABG procedure
IMPRESSION:
The study is degraded by incorrect bolus timing and motion artifact.
No acute hemorrhage or large territorial infarct.
Known bilateral punctate supra and infratentorial acute infarctions are better
appreciated on prior MRI head done ___. These infarcts are most likely
embolic in nature.
Within the limits of the study there is no intracranial arterial aneurysm or
occlusion. No ICA occlusion. No obvious ICA stenosis by NASCET criteria.
Increased soft tissues surrounding the junction of V3 and V4 segment of the
right vertebral artery may be secondary to accompanying veins or may represent
dissection, these cannot be differentiated due to poor contrast bolus timing
and repeat CTA is advised.
RECOMMENDATION(S): Increased soft tissues surrounding the junction of V3 and
V4 segment of the right vertebral artery may be secondary to accompanying
veins or may represent dissection, these cannot be differentiated due to poor
contrast bolus timing and repeat CTA or MR is advised if clinically indicated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dyspnea after blood transfusion// interval
change, ? pulmonary edema interval change, ? pulmonary edema
IMPRESSION:
Comparison to ___. Stable low lung volumes. Stable bilateral pleural
effusions of moderate extent. Stable subsequent bilateral areas of
atelectasis. Today's radiograph shows signs of mild pulmonary edema.
Unchanged alignment of the sternal wires. Unchanged right PICC line.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Laceration, s/p Fall
Diagnosed with Laceration without foreign body of nose, initial encounter, Fall on same level, unspecified, initial encounter
temperature: 98.6
heartrate: 84.0
resprate: 19.0
o2sat: 100.0
sbp: 121.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | SUMMARY:
___ man with PMHx notable for myelodysplastic syndrome
and relapsed high-grade ___ lymphoma with Burkitt-like
features, most recently on R-EPOCH (___), as well as HFrEF
(LVEF 31%) and ischemic cardiomyopathy, and recent admission for
MSSA bacteremia now re-admitted for mechanical fall with course
complicated by neutropenic fever / sepsis, rapid a-fib, acute
in-hospital delirium, and acute cardioembolic CVAs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Sulfa (Sulfonamide Antibiotics) /
trimethoprim / crab
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
trach change on ___
___ gastrostomy tube on ___
left triple-lumen IJ catheter with tip in the SVC on ___.
History of Present Illness:
___ morbidly obese female with recent diagnosis of
substernal multinodular goiter, right > left, with tracheal
compression status post open thyroid biopsy and tracheostomy
(___), also found to have concurrent DVT/PE in the setting
of aforementioned compression in R IJ and subclavian vein as
well as significant R-sided PE burden (right main, lobar,
segmental and subsegmental), currently subtherapeutic on
Coumadin on arrival to ___ ED, who presented from ___ with
persistent, severe anemia over the past 3 days. Per report, the
patient had a negative guaiac, negative C. difficile and was
subsequently transferred to ___ for further evaluation of
persistent anemia. No known trauma history. Supposedly, the
patient had been less responsive over the past few days, only
opening her eyes and looking around which is worse than her
baseline (per last ___ admission, responds to some questions,
mouths some words). No vomiting, diarrhea. No fevers or chills.
In the ED, the patient was placed on mechanical ventilation (CMV
Vt:380 RR:14 FiO2:0.4) for tachypnea and high minute volume
needs.
In the ED, initial vitals:
99.0, 120, 129/69, 22, 96% trach mask
Exam notable for:
Morbidly obese, opens her eyes and looks around, otherwise
unresponsive.
Bilateral upper extremity swelling with intact pulses
Lungs diminished
RRR +S1S2 tachycardic
No spinal tenderness, no CVAT
Abd with diffuse mild tenderness without clear focality
BLE with 1+ edema to the mid-shin with ___ intact
Rectal tube with brown stool, Guaiac negative
Labs notable for:
WBC: 23.2 (90% neuts) Hgb:5.6 Plt:257
138 / 93 /27 / AGap=13
------------- 200
3.5 / 32 /0.7\
___: 19.7 PTT: 150 INR: 1.8
Lactate 2.1 -> 1.7
Trop <0.01
Alb:23, AST:49, ALT:61, Alk Phos:103, TBili:0.6
Lipase: 55
Flu Negative
UA: Mod Blood, Large Leuks, Few Bacs, Many Yeast
Urine and Blood Cultures: Pending
Imaging:
CTA Abd Pelvis ___
1. Large right iliacus and right iliopsoas hematomas without
active
extravasation.
2. On postcontrast imaging, which scanned slightly more
inferiorly than the precontrast series, there are additional
smaller hematomas in the proximal right thigh without active
extravasation.
3. Bibasilar airspace opacities, similar on the right and
decreased on the left. Recommend clinical correlation to assess
for the possibility of pneumonia.
4. Decreased size of a moderate pericardial effusion. No
evidence of mass effect.
CT Head w/o Contrast ___
1. No evidence of intracranial hemorrhage or large territorial
infarction.
2. Increased bilateral mastoid effusions with extension into
the left middle ear cavity raising the possibility of
otomastoiditis. No evidence of osseous erosion.
3. New partial opacification of the paranasal sinuses with
aerosolized secretions raising the possibility of acute
sinusitis.
CXR ___
Bibasilar airspace opacities may reflect atelectasis though
infection is difficult to exclude in the correct clinical
setting. Persistent small bilateral pleural effusions with
probable mild pulmonary vascular congestion. Superior
mediastinal mass compatible with known thyroid goiter is better
assessed on previous CT.
CTA Chest ___
1. Pulmonary embolism in the right lower lobe is not well seen
and may be obscured due to artifact. Additional potential
filling defects in the bifurcation of the right pulmonary artery
may be artifactual or represent additional pulmonary emboli.
2. Re-demonstrated large retro sternal goiter that displaces
and compresses the trachea.
3. Re-demonstrated attenuation of the bilateral internal
jugular vein and right subclavian vein. The brachiocephalic and
SVC are patent.
4. Mild pericardial effusion is unchanged.
5. Additional findings above.
Patient received:
IV CefePIME
IVF NS (1000 mL ordered)
IV CefePIME 2 g
IV Heparin ___ units/hr
IV Vancomycin 1500 mg
Consults:
ENT-Appears to be moving air though trach tube well (crusting
on inner cannula cleaned by RT). Tracheoscopy clear to carina.
Neck soft and without evidence of hematoma (no ecchymosis, no
oozing from incision lines, no firmness aside from palpably
enlarged thyroid). No evident source for hematocrit drop on H&N
exam.
Vitals on transfer: 98.0, 128, 96/44, 24, 100% vent
Upon arrival to ___, the patient was unresponsive. ___ (RN
from ___ reported that the patient had been
unresponsive the entire time she was at the ___ and had
intermittent perioral twitching. Per daughter ___, the
patient had been mostly unresponsive since her thyroid biopsy
but occasionally was able to mouth a few words.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
Anterior mediastinal mass with tracheal compression
Right vocal fold paralysis
DVT/PE- presented to hospital from OSH with active DVT
Dyspnea/stridor
Hypothyroidism
Sensorineural hearing loss
Obesity
Breast Cancer
Social History:
___
Family History:
Per records, unknown family member with thyroid nodules
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 99.5, 137/85, 130, 20, 98%
GENERAL: unresponsive
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: occasional crackles, diminished breath sounds at the
bases
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, obese, non-tender, non-distended, bowel sounds
present
EXT: Warm, well perfused, 2+ pitting edema in UEs and ___
___: No obvious rashes
NEURO: reactive pupils, unresponsive
DISCHARGE PHYSICAL EXAM:
========================
___ 0757 Temp: 98.2 PO BP: 120/63 R Lying HR: 114 RR: 20 O2
sat: 96% O2 delivery: TM FSBG: 128
GENERAL: Awake in bed, appears in no acute distress, writing on
board
HEENT: Sclerae anicteric; trach site with light pink secretions
but site looks c/d/i, LIJ site c/d/i
CARDIOVASCULAR: Tachycardic, no murmurs
LUNGS: Anteriorly clear
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, PEG with tubefeeds
running
EXTREMITIES: both arms grossly edematous with trace pitting
edema
of right and 2+ of left. Both feet warm with 2+ pulses, unable
to
appreciate prior right thigh hematoma, right leg greater than
left, bilateral ankle with 2+ edema
NEURO: Face grossly symmetric. Moving all extremities
spontaneously but is bed bound. AOx3 and able to write and mouth
responses.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:55PM BLOOD WBC-23.2*# RBC-1.97* Hgb-5.6* Hct-18.2*
MCV-92 MCH-28.4 MCHC-30.8* RDW-16.5* RDWSD-53.0* Plt ___
___ 05:55PM BLOOD Neuts-90* Bands-0 Lymphs-5* Monos-3*
Eos-0 Baso-2* ___ Myelos-0 AbsNeut-20.88*
AbsLymp-1.16* AbsMono-0.70 AbsEos-0.00* AbsBaso-0.46*
___ 05:55PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:55PM BLOOD ___ PTT-150* ___
___ 05:55PM BLOOD Plt Smr-NORMAL Plt ___
___ 05:55PM BLOOD Glucose-200* UreaN-27* Creat-0.7 Na-138
K-3.5 Cl-93* HCO3-32 AnGap-13
___ 05:55PM BLOOD ALT-49* AST-61* AlkPhos-103 TotBili-0.6
___ 05:55PM BLOOD cTropnT-<0.01
___ 05:55PM BLOOD Albumin-2.3*
___ 03:38AM BLOOD Albumin-2.3* Calcium-7.1* Phos-3.7 Mg-2.2
___ 06:06PM BLOOD ___ Comment-GREEN TOP
___ 11:29PM BLOOD ___ pO2-25* pCO2-46* pH-7.48*
calTCO2-35* Base XS-8
___ 06:06PM BLOOD Lactate-2.1*
___ 11:29PM BLOOD O2 Sat-42
RELEVANT LABS:
==============
___ 03:38AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:55PM BLOOD cTropnT-<0.01
___ 03:38AM BLOOD TSH-3.7
___ 03:38AM BLOOD Free T4-0.9*
___ 03:38AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 03:38AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:38AM BLOOD HCV Ab-NEG
___ 03:46AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
___ 09:37PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 06:39AM BLOOD Ret Aut-8.0* Abs Ret-0.24*
___ 06:39AM BLOOD calTIBC-228* VitB12-1131* Hapto-<10*
Ferritn-887* TRF-175*
___ 09:29AM BLOOD Hapto-<10*
___ 06:36AM BLOOD %HbA1c-4.8 eAG-91
___ 06:39AM BLOOD TSH-6.5*
___ 07:29AM BLOOD 25VitD-13*
___ 06:00AM BLOOD 25VitD-16*
RELEVANT STUDIES/IMAGING:
=========================
CTA AP ___:
1. Large right iliacus and right iliopsoas hematomas without
active
extravasation.
2. On postcontrast imaging, which scanned slightly more
inferiorly than the precontrast series, there are additional
smaller hematomas in the proximal right thigh without active
extravasation.
3. Bibasilar airspace opacities, similar on the right and
decreased on the left. Recommend clinical correlation to assess
for the possibility of pneumonia.
4. Decreased size of a moderate pericardial effusion. No
evidence of mass effect.
CT Head w/o Contrast ___:
1. No evidence of intracranial hemorrhage or large territorial
infarction.
2. Increased bilateral mastoid effusions with extension into the
left middle ear cavity raising the possibility of
otomastoiditis. No evidence of osseous erosion.
3. New partial opacification of the paranasal sinuses with
aerosolized secretions raising the possibility of acute
sinusitis.
CXR ___:
Bibasilar airspace opacities may reflect atelectasis though
infection is difficult to exclude in the correct clinical
setting. Persistent small bilateral pleural effusions with
probable mild pulmonary vascular congestion. Superior
mediastinal mass compatible with known thyroid goiter is better
assessed on previous CT.
EEG ___:
This telemetry captured no pushbutton activations. Throughout,
it
showed a widespread mildly slow and disorganized background with
occasional bursts of generalized slowing, all suggesting a
widespread encephalopathy. Medications, metabolic disturbances,
and infection are among the most common causes. There were no
areas of prominent focal slowing. There were no epileptiform
features or electrographic seizures.
CT AP ___:
1. Extensive intramuscular hematomas involving several right
thigh
compartments, with involvement of the entire thigh to the level
of the knee as described above. Upper thigh involvement appears
slightly more extensive compared to ___, but there
is no active extravasation.
2. Minimal decrease in size of a now 11.1 x 8.1 x 4.7 cm right
iliacus muscle hematoma.
3. Incidental 2.6 x 2.2 cm right adnexal lesion with a coarse
calcification, for which the differential includes fibroma,
cystadenofibroma ___ tumor. In the absence of prior
imaging documenting stability, a pelvic ultrasound is
recommended for further evaluation.
4. Similar right greater than left bibasilar consolidations,
likely
representing atelectasis. Pneumonia is unlikely in the absence
of clinical symptoms.
5. Small pericardial effusion is likely similar accounting for
redistribution.
TTE ___:
IMPRESSION: Focused stat ICU study, suboptimal image quality.
Moderate, predominantly posterior pericardial effusion with
brief RV diastolic collapse consistent with impaired filling.
Compared with the prior study (images reviewed) of ___ the
effusion is slightly larger, still predominantly posterior and
there is now brief RV diastolic collapse. Image quality
suboptimal. Tachycardia now present. IVC not well visualized.
CTA AORTA/BIFEM/ILIAC ___:
1. Multiple, unchanged large intramuscular hematomas involving
the iliacus and anterior and medial compartments of the right
thigh. No new collection or evidence of active extravasation,
allowing for limitations of assessment. There is extensive
right lower extremity soft tissue edema.
2. Ventral abdominal wall hernia contains a loop of small bowel
without
complication.
TTE ___:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is a small to moderate sized pericardial effusion.
The effusion appears loculated and layers posteriorly. No
significant fluid is seen in the subcostal views. No respiratory
variation in inflow velocities is seen. There is an anterior
space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of ___,
RV diastolic collapse is no longer present on the parasternal
long axis views. The effusion appears similar in size to
slightly smaller. Heart rate has normalized.
LUE DOPPLER ___:
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Nonocclusive superficial thrombosis of the proximal cephalic
vein,
extending to the junction of the subclavian vein.
3. Fluid collection within the left biceps measure up to 6 cm in
long
dimension; this would be amenable to ultrasound-guided
aspiration if needed.
CT AP ___:
1. Interval increase in bibasilar atelectasis.
2. No significant change to a moderate pericardial effusion.
3. Worsening intra- and extrahepatic biliary dilation with the
common bile
duct measuring up to 2.9 cm (previously 2.2 cm).
4. No findings to explain hematuria. Specifically, no urinary
calculi, renal or urothelial lesion.
5. Stable right adnexal cyst with coarse calcification.
6. Evolving right iliopsoas and sartorius hematomas. The
sartorious is
slightly expanded from ___.
7. Incompletely assessed are severe degenerative changes of the
left wrist
with apparent osseous fusion of the carpal bones.
CT NECK W/ CONTRAST ___:
1. Re-identified is a 5.7 cm heterogeneous ill-defined left
thyroid mass
demonstrating central cystic components and coarse scattered
calcifications. Since the prior examination of ___, interval resolution of postoperative pneumocephalus and
soft tissue inflammatory stranding.
2. There remains loss of defined fascial plane between the mass
and the
adjacent trachea, esophagus and thyroid cartilage. In addition,
the lesion exerts right lateral mass effect on the right common
carotid artery, with obscuration of intervening fascial plane,
which appears progressed from prior examination. Although the
mass does not appear significantly increased in size since
examination of ___, the lack of improvement in
stranding and obscuration of adjacent fascial planes raises
concern for possible malignant process.
3. In addition, there is increased soft tissue prominence
incompletely
characterized at the visualized superior mediastinum posterior
to the trachea as well as apparent increased size of a 1.6 cm
paratracheal lymph node (series 304, image 147).
4. A spiculated left upper lobe lesion now measures 1 cm,
previously measuring 5-6 mm. A 4 mm right upper lobe pulmonary
nodule has also increased in size from prior examination.
Recommend further evaluation with dedicated CT chest.
5. Additional findings described above.
TRACHEAL BIOPSY PATHOLOGY ___:
Endotracheal biopsy: Squamous cell carcinoma, see n
ote.
Note: Lesional cells are positive for p40, CK5/6, a
nd PAX8. The carcinoma is morphologically
similar to the carcinoma seen in the patient's thyr
oid biopsy (___). Case reviewed by Drs. ___ and ___, who concur.
THYROID BIOPSY PATHOLOGY ___:
1. Thyroid/mediastinal mass, biopsy:
- Squamous cell carcinoma.
- Papillary thyroid carcinoma with extensive necros
is.
Note: The squamous cell carcinoma cells are positi
ve for p40, CK5/6, TTF-1, and PAX8. They are
negative for GATA3 and calcitonin. If the clinical
and radiologic findings are consistent with a
primary thyroid tumor, the overall findings are in
keeping with a squamous cell carcinoma of the
thyroid, tantamount to undifferentiated / anaplasti
c thyroid carcinoma. The necrotic papillary
carcinoma in the background is suggestive of origin
from a differentiated thyroid carcinoma.
2. Thyroid mass, biopsy: Scant necrotic tumor with
papillary architecture, favor necrotic papillary
carcinoma.
CXR ___:
Compared to chest radiographs since ___ most recently ___.
Lung volumes remain quite low. Atelectasis has worsened at the
left lung
base. Bilateral pleural effusions are likely, but not large.
Moderate to
severe cardiomegaly is chronic.
Tracheostomy tip projects over the upper trachea. No
pneumothorax or
mediastinal widening.
Left jugular line ends in the low SVC.
IP bronch ___:
PROCEDURE: flexible bronchoscopy, rigid bronchoscopy,
therapeutic
aspiration of secretions, tracheostomy revision OPERATORS:
___ FINDINGS: significant granulation
tissue and mass noted on posterior portion of trachea, no active
bleeding.
TTE ___:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are structurally normal. There is a small
pericardial effusion, primarily posterior to the left ventricle.
There is no free fluid anterior to the RV.
IMPRESSION: Small loculated pericardial effusion
DISCHARGE LABS
___ 06:09AM BLOOD WBC: 12.6* RBC: 3.00* Hgb: 8.7* Hct:
29.4* MCV: 98 MCH: 29.0 MCHC: 29.6* RDW: 14.9 RDWSD: 53.6* Plt
Ct: 223
___ 06:09AM BLOOD ___: 12.2 PTT: 25.4 ___: 1.1
___ 06:09AM BLOOD Glucose: 148* UreaN: 17 Creat: 0.4 Na:
139 K: 4.5 Cl: 94* HCO3: 39* AnGap: 6*
___ 06:09AM BLOOD ALT: 12 AST: 14 LD(LDH): 222 AlkPhos:
106* TotBili: 0.4
___ 06:09AM BLOOD Calcium: 9.2 Phos: 3.3 Mg: 2.1
___ 05:19AM BLOOD Lupus: Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE Liquid 5 mg PO Q6H:PRN BREAKTHROUGH PAIN
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 75 mg PO Q8H
4. Senna 8.6 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Acetaminophen (Liquid) 975 mg PO Q8H:PRN Pain - Mild/Fever
9. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
10. Ranitidine 150 mg PO BID
11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
12. Omeprazole 40 mg PO DAILY
13. Warfarin 4 mg PO DAILY16
Discharge Medications:
CURRENT MEDICATIONS ___ as of 15:13
--------------- --------------- --------------- ---------------
Active Inpatient Medication list as of ___ at 1514:
Medications - Standing
Levothyroxine Sodium 50 mcg PO/NG DAILY
Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
Multivitamins W/minerals Liquid 15 mL PO/NG DAILY
Acetaminophen 650 mg PO/NG Q8H
Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line flush
Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush
Acetylcysteine 20% ___ mL NEB Q4H shortness of breath, increased
secretions
Albuterol 0.083% Neb Soln 1 NEB IH Q4H Dyspnea
Guaifenesin-Dextromethorphan 5 mL PO/NG Q6H
OxyCODONE (Immediate Release) 2.5 mg PO/NG Q6H
ClonazePAM 0.25 mg PO/NG TID
Vitamin D 1000 UNIT PO/NG DAILY
Heparin 5000 UNIT SC TID
Polyethylene Glycol 17 g PO/NG DAILY
Medications - PRN
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Glucose Gel 15 g PO PRN hypoglycemia protocol
Docusate Sodium 100 mg PO/NG BID:PRN constipation
Ramelteon 8 mg PO/NG QHS:PRN insomnia
Artificial Tears ___ DROP BOTH EYES PRN dry eyes
Heparin Flush (10 units/ml) 1 mL IV PRN and PRN, line flush
LORazepam 0.5 mg PO/NG Q6H:PRN anxiety
OxycoDONE Liquid 5 mg PO/NG Q4H:PRN pain, dyspea
Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
Senna 8.6 mg PO/NG DAILY:PRN constipation
Bisacodyl 10 mg PR QHS:PRN constipation
Lidocaine Viscous 2% 15 mL PO TID:PRN toothache
--------------- --------------- --------------- ---------------
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Anaplastic thyroid cancer
Chronic respiratory failure secondary to obstruction from goiter
Hemorrhagic shock from right ___ acquired pneumonia
Pulmonary embolism
Right internal jugular thrombus
Pericardial effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with tachycardia, evaluate for pneumonia
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: CT chest and chest radiograph ___
FINDINGS:
Tracheostomy tube is in unchanged position. Left-sided PICC tip terminates at
the SVC/right atrial junction. Enteric tube tip is within the stomach. Lung
volumes are low. Moderate cardiac silhouette enlargement is re-demonstrated.
Mediastinal and hilar contours are similar with known superior mediastinal
mass better assessed on the previous CT. Crowding of bronchovascular
structures is noted with probable mild pulmonary vascular congestion.
Bibasilar airspace opacities likely reflect areas of atelectasis, though
infection is not completely excluded in the left lung base. Small bilateral
pleural effusions are likely not substantially changed in the interval. No
pneumothorax is identified. No acute osseous abnormalities detected. Clips
in the right upper quadrant of the abdomen are noted.
IMPRESSION:
Bibasilar airspace opacities may reflect atelectasis though infection is
difficult to exclude in the correct clinical setting. Persistent small
bilateral pleural effusions with probable mild pulmonary vascular congestion.
Superior mediastinal mass compatible with known thyroid goiter is better
assessed on previous CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with ___ with altered mental status. Eval for intracranial
hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 17.4 cm; CTDIvol = 46.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 0.8 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: ___ noncontrast head CT
FINDINGS:
There is no evidence of acute territorial infarction,hemorrhage,edema, or
mass. Periventricular and subcortical white matter hypodensities are
nonspecific but likely sequelae of chronic small vessel ischemic disease.
There is prominence of the ventricles and sulci suggestive of involutional
changes.
A 2.7 x 1.1 cm subcutaneous soft tissue nodule overlying the right occiput is
unchanged since 2 weeks prior. There is no evidence of fracture. Incidental
mild hyperostosis frontalis interna. There is new partial opacification of
the right frontal sinus, ethmoid air cells, sphenoid sinuses, right maxillary
sinus, and right nasal cavity with aerosolized secretions. A nasoenteric
catheter is partially imaged. There is increased patchy opacification of the
bilateral mastoid air cells with new extension through the left aditus ad
antrum into the left middle ear cavity. The right petrous apex is pneumatized
with partial opacification. No evidence of osseous erosion. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of intracranial hemorrhage or large territorial infarction.
2. Increased bilateral mastoid effusions with extension into the left middle
ear cavity raising the possibility of otomastoiditis. No evidence of osseous
erosion.
3. New partial opacification of the paranasal sinuses with aerosolized
secretions raising the possibility of acute sinusitis.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ with H/H drop on heparin. minimally responsive with
difficult physical exam. eval for intra-abd bleeding.
TECHNIQUE: Noncontrast abdomen/pelvis CT: Axial images were obtained through
the abdomen and pelvis. Subsequent CTA through the pelvis was performed.
Coronal and sagittal reformats were performed.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 27.7 mGy (Body) DLP =
1,467.8 mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 22.8 mGy (Body) DLP =
11.4 mGy-cm.
3) Spiral Acquisition 5.4 s, 42.3 cm; CTDIvol = 14.9 mGy (Body) DLP = 628.4
mGy-cm.
4) Spiral Acquisition 5.4 s, 42.3 cm; CTDIvol = 14.9 mGy (Body) DLP = 628.4
mGy-cm.
Total DLP (Body) = 2,736 mGy-cm.
COMPARISON: ___ CT abdomen
___ chest CTA
FINDINGS:
LOWER CHEST: A simple moderate size pericardial effusion appears slightly
smaller since ___ without evidence of mass effect. There is a
trace right pleural effusion. There is persistent right basilar
atelectasis/consolidation with air bronchograms. There is decreased left
basilar atelectasis/consolidation with air bronchograms.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions within limitations of noncontrast CT. There
is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: The pancreas is moderately atrophic. No focal lesions or pancreatic
ductal dilation identified. No peripancreatic fat stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits, noting
placement of a rectal catheter. Appendix contains air, has normal caliber
without evidence of fat stranding. There is no evidence of mesenteric
lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder is decompressed with a Foley catheter in place.
There is no evidence of pelvic or inguinal lymphadenopathy. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is anteverted with a calcified fibroid in the
right aspect of the uterine fundus.
VASCULAR: No infrarenal abdominal aortic aneurysm. Calcified atherosclerosis
is mild. Dilated gonadal veins bilaterally with prominent pelvic varices may
suggest pelvic congestion syndrome in the correct clinical setting.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is mild bilateral hip osteoarthritis.
SOFT TISSUES: A right iliacus hematoma measures 12.9 x 9.1 x 5.9 cm (series
601, image 43; series 3, image 62). A right iliopsoas hematoma measures at
least 16.5 x 5.5 x 4.6 cm (series 601, image 38; series 3, image 91). On
postcontrast imaging, which scanned slightly more inferiorly than the
precontrast series, there are additional smaller hematomas in the proximal
right thigh. There is no active extravasation. Note is made of mild anasarca.
There are bilateral fat containing inguinal hernias and a small fat containing
umbilical hernia.
IMPRESSION:
1. Large right iliacus and right iliopsoas hematomas without active
extravasation.
2. On postcontrast imaging, which scanned slightly more inferiorly than the
precontrast series, there are additional smaller hematomas in the proximal
right thigh without active extravasation.
3. Bibasilar airspace opacities, similar on the right and decreased on the
left. Recommend clinical correlation to assess for the possibility of
pneumonia.
4. Decreased size of a moderate pericardial effusion. No evidence of mass
effect.
Radiology Report
INDICATION: ___ year old woman with chronic trach concern for pneumonia//
evaluate for progression of infiltrate
TECHNIQUE: Frontal radiograph of the chest.
COMPARISON: ___.
IMPRESSION:
Opacity of the left lung base appears similar may reflect left pleural
effusion and atelectasis, however consolidative opacity cannot be excluded.
Mild bilateral pulmonary edema similar to slightly increased from prior exam.
Tracheostomy is partially visualized. NG tube is seen with tip projecting
over left upper quadrant, side-hole may be near the GE junction, similar to
prior exam. Left-sided PICC is seen with tip projecting over the right
atrium, similar to prior exam.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with left sided PICC with LUE>RUE swelling with
known R IJ and R Subclavian DVT secondary to substernal thyroid goiter// LUE
DVT?
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: ___.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
PICC is seen within the left cephalic vein. Again seen is a superficial fluid
collection in the left biceps area measuring approximately 8.7 x 2.5 x 3.2 cm.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity. Unchanged
superficial fluid collection in the left anterior upper arm.
Radiology Report
INDICATION: ___ year old woman with respiratory distress// is there pneumonia,
mucus plug?
TECHNIQUE: Frontal radiograph of the chest.
COMPARISON: ___.
IMPRESSION:
Left-sided PICC is seen with tip projecting at the cavoatrial junction/right
atrium. NG tube is seen with tip projecting over left upper quadrant and
side-hole likely at the GE junction. Tracheostomy catheter is again seen.
Low lung volumes. Opacity at the left lung base appears similar and may
reflect a combination of effusion and atelectasis. Consolidative opacity
cannot be excluded. Mild bilateral pulmonary edema appears similar. Likely
small right pleural effusion. The cardiac silhouette appears unchanged.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with pneumonia and respiratory distress.//
pulmonary edema? worsening infiltrate
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___ 05:00
IMPRESSION:
Compared to the earlier same day examination, upper enteric tube and
tracheostomy tube as well as a left-sided PICC are unchanged. Lung volumes
remain very low. Retrocardiac consolidation appears similar. There may be a
tiny right-sided effusion, unchanged. There is no pneumothorax. The upper
lung zones remain clear.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman presented with thigh hematomas, now restarted
heparin gtt, R thigh now indurated, patient tachycardic/hypotensive and Hgb
7.6-> 6.0// looking for active extravasation into thigh hematomas, most
notably on the R
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis, including the thighs.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE:
Total DLP: 1435 mGy-cm
COMPARISON: CTA abdomen and pelvis ___
FINDINGS:
VASCULAR:
Abdominal aorta is non aneurysmal. Celiac artery and its branches are patent.
SMA, ___, and bilateral renal arteries are patent. Bilateral internal and
external iliac arteries are patent. Normal right femoral artery.
LOWER CHEST: Right greater than left enhancing bibasilar consolidations likely
represent atelectasis. No pleural effusion. Small pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is is resected.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits. There
is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: Urinary bladder is collapsed around a Foley catheter, with post
instrumentational intraluminal air. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Calcified fibroid in the uterus. Right adnexal lesion
measures approximately 2.6 x 2.2 cm, containing a coarse calcification
(10:122). No adnexal masses are identified on the left.
BONES: No acute fracture. Bony structures demineralized.
SOFT TISSUES: Intramuscular hematoma in the right iliacus muscle measures 4.7
x 8.1 x 11.1 cm TV x AP x CC (6:126, 8:62), measuring up to 4.9 x 8.8 x 12.8
cm on ___.
Evaluation of the soft tissues is notable for extensive areas of intramuscular
hematoma involving several compartments of the right thigh. For instance,
hematoma measures up to 18.4 x 8.6 cm in the right sartorius muscle (08:43).
There is expansion of the entire vastus lateralis muscle, measuring up to 34.9
x 9.9 cm CC x TV (08:50). There is also intramuscular hematoma in the
adductor compartment, measuring up to 14.7 x 6.4 cm (8:79). When compared to
the prior study on ___, the hematomas within the upper thigh
muscles appear slightly expanded, but was not fully imaged on the prior study.
However, there is no evidence of active extravasation on the arterial or
venous phase.
Additionally, there is significant subcutaneous edema that has increased from
prior.
Limited evaluation of the partially imaged right knee joint shows a small
joint effusion.
IMPRESSION:
1. Extensive intramuscular hematomas involving several right thigh
compartments, with involvement of the entire thigh to the level of the knee as
described above. Upper thigh involvement appears slightly more extensive
compared to ___, but there is no active extravasation.
2. Minimal decrease in size of a now 11.1 x 8.1 x 4.7 cm right iliacus muscle
hematoma.
3. Incidental 2.6 x 2.2 cm right adnexal lesion with a coarse calcification,
for which the differential includes fibroma, cystadenofibroma ___
tumor. In the absence of prior imaging documenting stability, a pelvic
ultrasound is recommended for further evaluation.
4. Similar right greater than left bibasilar consolidations, likely
representing atelectasis. Pneumonia is unlikely in the absence of clinical
symptoms.
5. Small pericardial effusion is likely similar accounting for redistribution.
RECOMMENDATION(S): Nonurgent pelvic ultrasound is recommended if prior
imaging is not available for comparison.
NOTIFICATION: The findings and recommendation were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 8:21 am, 2
minutes after discovery of the findings.
Radiology Report
INDICATION: ___ with goiter causing tracheal narrowing now s/p trach ___,
also with history of PE's on Coumadin who presents with thigh hematomas
causing anemia, found to have fevers, leukocytosis, and worsening mental
status. Suspect HCAP, treating with Zosyn.// NG placement
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Tracheostomy tube and NG tube are unchanged. There is subsegmental
atelectasis in the right lung base. Cardiomediastinal silhouette is stable.
Small bilateral effusions are stable. No pneumothorax is seen. Lungs are low
volume. There is no evidence of pulmonary edema. Right upper lobe
atelectasis has improved.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ year old woman with hematomas in pelvis thighs, and ongoing
bleeding requiring pressors. possible ___ embolization// Please do CTA of
pelvis proximal lower extremities (to the knees). She has known hematomas
there
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 12.8 s, 83.4 cm; CTDIvol = 1.8 mGy (Body) DLP = 144.9
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 5.8 mGy (Body) DLP = 1.2
mGy-cm.
3) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 23.0 mGy (Body) DLP = 4.6
mGy-cm.
4) Stationary Acquisition 6.6 s, 0.2 cm; CTDIvol = 111.7 mGy (Body) DLP =
22.3 mGy-cm.
5) Spiral Acquisition 12.8 s, 83.2 cm; CTDIvol = 17.5 mGy (Body) DLP =
1,443.0 mGy-cm.
Total DLP (Body) = 1,616 mGy-cm.
COMPARISON: CT ___
FINDINGS:
VASCULAR: There is no abdominal aortic aneurysm. The SMA and ___ are patent.
The celiac artery is not entirely visualized.
Intramuscular hematoma within the right iliacus is unchanged from ___ with the iliacus measuring up to 8.6 x 5.0 cm.
Several large intramuscular hematomas involving primarily the anterior and
medial compartment are unchanged. For example, the sartorius, rectus femoris,
vastus lateralis, vastus intermedius, vastus medialis, are significantly
increased in size but unchanged from ___. Allowing for single
phase contrast enhanced technique, no new collection or active extravasation.
ABDOMEN: (Upper abdomen partially visualized.)
HEPATOBILIARY: The visualized liver is unremarkable. The gallbladder is
surgically absent.
PANCREAS: The visualized pancreas is unremarkable.
SPLEEN: The visualized spleen is within normal limits.
ADRENALS: The visualized adrenal glands unremarkable.
URINARY: No suspicious renal mass identified. No hydronephrosis.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Colon and rectum are within normal limits. There
is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Fibroid uterus is noted. No adnexal abnormality.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Subchondral cystic degenerative change noted at the hip joints, bilaterally.
There is a small right knee joint effusion.
The patient is status post ORIF of a left tibial fracture. No evidence of
hardware complication.
SOFT TISSUES: Ventral abdominal hernia containing a loop of small bowel
without evidence of complication.
IMPRESSION:
1. Multiple, unchanged large intramuscular hematomas involving the iliacus and
anterior and medial compartments of the right thigh. No new collection or
evidence of active extravasation, allowing for limitations of assessment.
There is extensive right lower extremity soft tissue edema.
2. Ventral abdominal wall hernia contains a loop of small bowel without
complication.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with trach and recently tx for PNA. Now with
increased respiratory distress.// Assess for worsening PNA vs pulmonary edema.
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: ___.
IMPRESSION:
Compared to the prior examination, lung volumes are lower, further
accentuating the cardiac silhouette and pulmonary vasculature. Tracheostomy
tube, left PICC, and upper enteric tube are unchanged. There is moderate
cardiomegaly. No gross consolidation is seen. There are probable small
persistent bilateral pleural effusions. There is no pneumothorax.
Radiology Report
INDICATION: ___ year old woman with NGT// NGT placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The patient is rotated. A tracheostomy tube is present. The tip of the
nasogastric tube projects over the stomach. The left PICC line tip loops back
on itself pointing cranially and may be malpositioned in the azygos vein.
Low bilateral lung volumes cause bronchovascular crowding. There are small
bilateral pleural effusions with subjacent atelectasis. Superimposed
pulmonary vascular congestion is likely present. The appearance of the
cardiac silhouette is unchanged.
IMPRESSION:
The tip of the feeding tube projects over the stomach.
Suspected malpositioned left PICC line with the tip appearing to project over
the azygos vein. A repeat frontal radiograph without patient rotation is
recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:25 pm, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with ? of a malpositioned PICC. Please confirm
PICC line tip placement. PICC line has been power flushed// ? of a
malpositioned PICC in azygous vein on previous CXR. Please confirm placement.
TECHNIQUE: AP portable chest radiograph
COMPARISON: Chest radiograph from earlier today
IMPRESSION:
There are low bilateral lung volumes and the patient is again noted to be
rotated. The left PICC line tip is now flipped downward and leftward, still
appearing malpositioned. Unchanged cardiopulmonary findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Ms. ___ is a ___ year old woman with hypothyroidism, goiter
since ___, sensorineural hearing loss, morbid obesity and recent admission
___ for tracheal obstruction and right vocal cord paralysis secondary
to enlarged goiter requiring tracheostomy, with course complicated by
diagnosis of PE/RIJ DVT/R subclavian DVT discharged on warfarin, who was
admitted ___ from her LTACH with hemorrhagic shock from right
iliopsoas/thigh hematoma and HCAP. Her course has been complicated by
pericardial effusion and volume overload.// increased tachypneaincreased
tachypnea
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous mild pulmonary edema has resolved, although vessels are crowded by
chronically elevated right hemidiaphragm. Moderate cardiomegaly is chronic.
Small pleural effusions are likely. No pneumothorax.
Tracheostomy tube midline. Nasogastric drainage tube passes into the stomach
and out of view.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: hypothyroidism, goiter since ___, sensorineural hearing loss,
morbid obesity and recent admission ___ for tracheal obstruction and
right vocal cord paralysis secondary to enlarged goiter requiring
tracheostomy, with course complicated by diagnosis of PE/RIJ DVT/R subclavian
DVT discharged on warfarin, who was admitted ___ from her LTACH with
hemorrhagic shock from right iliopsoas/thigh hematoma and HCAP. Her course has
been complicated by pericardial effusion and volume overload. Worsening LUE
swelling compared to right
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial and basilic veins are patent,
compressible and show normal color flow and augmentation.
At the junction of the left subclavian vein, the cephalic vein is mildly
distended, noncompressible, and demonstrates decreased flow on color Doppler
imaging, consistent with nonocclusive superficial thrombosis. At this time a
thrombosis does not extend into the subclavian vein.
Additionally, within the left biceps, a fluid collection measuring 2.9 x 2.1 x
6.0 cm is identified without increased peripheral vascularity. This would be
amenable to ultrasound-guided aspiration if desired.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Nonocclusive superficial thrombosis of the proximal cephalic vein,
extending to the junction of the subclavian vein.
3. Fluid collection within the left biceps measure up to 6 cm in long
dimension; this would be amenable to ultrasound-guided aspiration if needed.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, RDMS on the telephone on ___ at 11:55 am, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: Ultrasound-guided aspiration
INDICATION: ___ year old woman with goiter s/p trach, diffuse overload, large
LUE fluid collection// LUE collection to be drained by US, spoke to US team
COMPARISON: ___
PROCEDURE: Ultrasound-guided drainage of a left arm collection.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr.
___ supervised the trainee during the key components of the
procedure and reviewed and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for aspiration was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, a 15 gauge needle was advanced into the
left arm collection. Approximately 2 cc of sanguinous fluid was aspirated and
sent for microbiology evaluation. The remainder of the fluid could not be
aspirated due to the consistency of the collection.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: No sedation was provided.
FINDINGS:
Preprocedure ultrasound re-demonstrated a collection in the left upper arm.
IMPRESSION:
US-guided aspiration of a collection in the left upper arm, yielding 2 cc of
sanguinous fluid. This most likely represents a hematoma. Aspirate was sent
for microbiology evaluation.
Radiology Report
INDICATION: ___ year old woman with goiter, rij clot and left cephalic clot
with BUE swelling and RLE swelling from hematoma, makes exam difficult and
want to assess volume status and need for diuresis// eval for pulm edema
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Tracheostomy tube remains in
place. The NG tube is unchanged. Cardiomediastinal silhouette is stable.
There are stable small bilateral pleural effusions no pneumothorax is seen
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman with goiter s/p trach, evaluating swelling and
need for repeat biopsy// evaluate neck/throat swelling
TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.0 s, 23.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 195.0
mGy-cm.
Total DLP (Body) = 195 mGy-cm.
COMPARISON: CTA chest with without contrast of ___, CT neck without contrast of ___, outside hospital CT chest
of ___.
FINDINGS:
Re-identified is 5.6 x 4.2 x 5.7 cm (AP, TRV, SI) heterogeneous ill-defined
left thyroid mass, demonstrating central cystic components and coarse
scattered coarse calcifications extending into the superior mediastinum. As
on prior examinations, the fascial planes between the lesion and the adjacent
trachea and esophagus (series 304, image 139) and thyroid cartilage (series
304, image 87) remains obscured. The lesion abuts the right common carotid
artery (series 304, image 147), with right lateral displacement, overall
similar to prior examination, however the intervening fascial plane is also
obscured, with possible increasing surrounding stranding (series 304, image
126). Interval resolution of postsurgical subcutaneous emphysema. The
patient is status post tracheostomy, unchanged in appearance from prior
examination. The left lobe of the thyroid is also mildly enlarged and
heterogeneous, with coarse calcifications and hypoattenuating nodules,
unchanged from prior examination. The fascial planes between the left lobe
and adjacent structures appear grossly preserved. An enteric tube is also
identified. No cervical lymphadenopathy is identified. However, there
appears to be increased soft tissue density in the visualized superior
mediastinum posterior to the trachea with interval increased size of a lymph
node adjacent to the esophagus at the level of the aortic arch (series 304,
image 147).
Allowing for sequela of tracheostomy and enteric tube, the remainder of the
aerodigestive tract is grossly unremarkable. The major salivary glands are
unremarkable.
A spiculated left upper lobe pulmonary nodule measuring 1 cm has significantly
increased in size since examination of ___ (series 304, image
108). A 4 mm nodule in the right upper lobe (series 304, image 147) appears
slightly increased in size as well.
Dependent mucus is seen in the visualized right maxillary sinus and there is
near complete opacification of the visualized sphenoid sinuses. Near complete
opacification of the bilateral mastoid air cells is also noted. No acute
osseous abnormality.
IMPRESSION:
1. Re-identified is a 5.7 cm heterogeneous ill-defined left thyroid mass
demonstrating central cystic components and coarse scattered calcifications.
Since the prior examination of ___, interval resolution of
postoperative pneumocephalus and soft tissue inflammatory stranding.
2. There remains loss of defined fascial plane between the mass and the
adjacent trachea, esophagus and thyroid cartilage. In addition, the lesion
exerts right lateral mass effect on the right common carotid artery, with
obscuration of intervening fascial plane, which appears progressed from prior
examination. Although the mass does not appear significantly increased in
size since examination of ___, the lack of improvement in
stranding and obscuration of adjacent fascial planes raises concern for
possible malignant process.
3. In addition, there is increased soft tissue prominence incompletely
characterized at the visualized superior mediastinum posterior to the trachea
as well as apparent increased size of a 1.6 cm paratracheal lymph node (series
304, image 147).
4. A spiculated left upper lobe lesion now measures 1 cm, previously measuring
5-6 mm. A 4 mm right upper lobe pulmonary nodule has also increased in size
from prior examination. Recommend further evaluation with dedicated CT chest.
5. Additional findings described above.
RECOMMENDATION(S): Recommend further evaluation of impression 4 with
dedicated CT chest with without contrast.
Radiology Report
INDICATION: ___ year old woman with goiter s/p trach with RIJ clot and now
with left cephalic/subclavian likely triggered by midline in the left, which
is now more distal but she needs heparin for the clot// ***spoke to ___
___ place temporary left IJ and remove left midline due to clot,
patient also scheduled for PEG, ___ aware ; ___ year old woman with
goiter causing tracheal compression now s/p trach by ENT, per speech and
swallow not yet safe to take POs or in the immediate future and will need G
tube. **Of note, patient on heparin gtt and receiving tubefeeds through NGT at
this time. Patient is also hard of hearing and requires writing for
communication// G tube placement
COMPARISON: CT from ___
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
125 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service
time of 25 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl and Versed for moderate sedation as above, 1% local
lidocaine, 1% lidocaine with epinephrine, 1 mg glucagon
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.9 min, 16 mGy
PROCEDURE: 1. Placement of triple lumen left internal jugular catheter
2. Placement of a MIC gastrostomy tube placement.
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The left neck was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath.
The Nitinol wire was removed and ___ wire was advanced into the IVC. A
triple-lumen central venous catheter was advanced over the wire into the
superior vena cava with the tip in the cavoatrial junction. All 3 access ports
were aspirated, flushed and capped. The catheter was secured to the skin with
a 0 silk suture and sterile dressings were applied. Final spot fluoroscopic
image demonstrating good alignment of the catheter and no kinking.
Attention was then turned to the placement of the feeding tube. A scout image
of the abdomen was obtained. The stomach was insufflated through the
indwelling nasogastric tube. Using a marker, theskin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A ___ wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
After sequential dilation using serial dilators, a ___ gastrostomy
catheter was advanced over the wire into position. The catheter was secured by
forming the retaining loop in the stomach after confirming the position of the
catheter with a contrast injection.. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
FINDINGS:
1. Successful placement of a ___ gastrostomy tube.
2. Successful placement of left triple-lumen IJ catheter with tip in the SVC.
IMPRESSION:
Successful placement of a ___ gastrostomy tube and triple-lumen
catheter.
Radiology Report
INDICATION: ___ year old woman with goiter s/p trach with RIJ clot and now
with left cephalic/subclavian likely triggered by midline in the left, which
is now more distal but she needs heparin for the clot// ***spoke to ___
___ place temporary left IJ and remove left midline due to clot,
patient also scheduled for PEG, ___ aware ; ___ year old woman with
goiter causing tracheal compression now s/p trach by ENT, per speech and
swallow not yet safe to take POs or in the immediate future and will need G
tube. **Of note, patient on heparin gtt and receiving tubefeeds through NGT at
this time. Patient is also hard of hearing and requires writing for
communication// G tube placement
COMPARISON: CT from ___
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
125 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service
time of 25 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl and Versed for moderate sedation as above, 1% local
lidocaine, 1% lidocaine with epinephrine, 1 mg glucagon
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.9 min, 16 mGy
PROCEDURE: 1. Placement of triple lumen left internal jugular catheter
2. Placement of a MIC gastrostomy tube placement.
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The left neck was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath.
The Nitinol wire was removed and ___ wire was advanced into the IVC. A
triple-lumen central venous catheter was advanced over the wire into the
superior vena cava with the tip in the cavoatrial junction. All 3 access ports
were aspirated, flushed and capped. The catheter was secured to the skin with
a 0 silk suture and sterile dressings were applied. Final spot fluoroscopic
image demonstrating good alignment of the catheter and no kinking.
Attention was then turned to the placement of the feeding tube. A scout image
of the abdomen was obtained. The stomach was insufflated through the
indwelling nasogastric tube. Using a marker, theskin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Permanent ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. A ___ wire was
introduced into the stomach. A small skin incision was made along the needle
and the needle was removed.
After sequential dilation using serial dilators, a ___ gastrostomy
catheter was advanced over the wire into position. The catheter was secured by
forming the retaining loop in the stomach after confirming the position of the
catheter with a contrast injection.. Sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
FINDINGS:
1. Successful placement of a ___ gastrostomy tube.
2. Successful placement of left triple-lumen IJ catheter with tip in the SVC.
IMPRESSION:
Successful placement of a ___ gastrostomy tube and triple-lumen
catheter.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT AND WITH INTRAVENOUS CONTRAST
INDICATION: ___ year old woman with goiter s/p trach, multiple clots on
heparin gtt, with new hematuria// CT urogram to evaluate hematuria*patient
going down for neck CT today, would appreciate if could do at same time as she
has a trach and needs nursing to go with her*
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
supine position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 58.7 cm; CTDIvol = 5.6 mGy (Body) DLP = 328.7
mGy-cm.
2) Spiral Acquisition 4.4 s, 58.7 cm; CTDIvol = 24.3 mGy (Body) DLP =
1,423.3 mGy-cm.
3) Stationary Acquisition 8.5 s, 0.5 cm; CTDIvol = 47.0 mGy (Body) DLP =
23.5 mGy-cm.
Total DLP (Body) = 1,775 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
LOWER CHEST: Bibasilar atelectasis has increased from 2 weeks prior. Trace
bilateral pleural effusions are unchanged. A moderate pericardial effusion is
grossly unchanged.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. The common bile duct is significantly
dilated measuring up to 2.9 cm, previously 2.4 cm. There is moderate
intrahepatic ductal dilation. The gallbladder is surgically absent
PANCREAS: Pancreas is atrophic. Remaining pancreatic parenchyma is normally
enhancing. No focal lesions or ductal dilation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no nephrolithiasis or ureterolithiasis. There is no hydronephrosis.
There is no perinephric abnormality. Several bilateral subcentimeter
hypodensities are too small to characterize, but most likely represent simple
cysts. There is no evidence of urothelial lesions. The distal ureters are
unremarkable. The bladder contains a Foley catheter and is otherwise grossly
unremarkable.
GASTROINTESTINAL: An enteric tube terminates in the mid stomach. There is
also a percutaneous gastrostomy tube also terminating in the gastric body.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. The colon and rectum are within normal limits. The appendix is not
seen.
PELVIS: There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: There are calcified fibroids in the uterus. A right
adnexal cyst with internal calcification measures 3 cm, unchanged. No left
adnexal lesion is identified.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Subacute left 7th rib fracture is noted. A left 6th rib fracture is chronic.
Incompletely evaluated is severe degenerative change to the left wrist with
apparent fusion of the carpal bones.
SOFT TISSUES: There has been interval evolution of a hematoma involving the
right iliacus and extending into the iliopsoas. Hematoma in the right
sartorius muscle is also noted, and the muscle appears slightly expanded
measuring 5.0 x 8.5 cm (3:106)
IMPRESSION:
1. Interval increase in bibasilar atelectasis.
2. No significant change to a moderate pericardial effusion.
3. Worsening intra- and extrahepatic biliary dilation with the common bile
duct measuring up to 2.9 cm (previously 2.2 cm).
4. No findings to explain hematuria. Specifically, no urinary calculi, renal
or urothelial lesion.
5. Stable right adnexal cyst with coarse calcification.
6. Evolving right iliopsoas and sartorius hematomas. The sartorious is
slightly expanded from ___.
7. Incompletely assessed are severe degenerative changes of the left wrist
with apparent osseous fusion of the carpal bones.
RECOMMENDATION(S): MRCP for further evaluation of worsening biliary dilation.
Pelvic ultrasound.
Left wrist radiographs.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with goiter, unsure if cancer, with increasing
size of spiculated lung nodule, evaluate spiculated nodule
TECHNIQUE: MDCT axial images were obtained through the chest after the
uneventful administration of intravenous contrast. Coronal and sagittal and
axial MIPS reformatted images were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 34.2 cm; CTDIvol = 20.4 mGy (Body) DLP = 696.8
mGy-cm.
2) Spiral Acquisition 0.7 s, 11.2 cm; CTDIvol = 20.4 mGy (Body) DLP = 228.0
mGy-cm.
Total DLP (Body) = 925 mGy-cm.
COMPARISON: CTA chest ___, CTA neck ___
FINDINGS:
Again seen is a massively enlarged right neck soft tissue mass compatible with
the known thyroid mass with central cystic components and coarse
calcifications extending beyond the thoracic inlet in into the anterior
mediastinum. Overall size has not significantly changed compared to prior
examinations, and measures 6.7 x 7.8 x 7.3 cm. There is again mass effect on
the trachea with loss of intervening fat planes and leftward displacement. A
tracheostomy tube is in place and the airway is open. There is also loss of
fat plane between this mass and the esophagus and thyroid cartilage as well as
the right common carotid artery. There is no right carotid narrowing. Unable
to evaluate for venous anatomy patency given phase of contrast.
The left thyroid is also enlarged with multiple coarsely calcified nodules,
but does not extend below the thoracic inlet.
Heart is moderately enlarged. There is a small pericardial effusion.
Numerous mildly enlarged mediastinal lymph nodes are unchanged measuring up to
1.0 cm in the precarinal station. There is no axillary adenopathy.
The airways are patent to the segmental level bilaterally. There are small
right greater than left pleural effusions with bibasilar atelectasis also more
pronounced on the right. Again seen is a 1.0 cm left apical pulmonary nodule
which demonstrates interval increase in size since CTs from 1 month prior but
no change compared to yesterday's CT (series 302, image 30). There is no
pneumothorax.
A nasoenteric tube is in place ending in the stomach. Limited views of the
upper abdomen are unremarkable.
There is no suspicious bony lesion. Multiple healing rib fractures are noted
involving the left lateral fourth through seventh ribs. There is a leftward
upper thoracic scoliosis. Note is made of a left humeral fixation plate and
interlocking screws.
IMPRESSION:
1. No change in size of the known large partially cystic right thyroid mass
causing contralateral (left lower) displacement and compression of the
adjacent trachea with obscuration of the fascial plane between the esophagus,
trachea, thyroid cartilage, and right internal carotid artery. The trachea is
patent via presence of a tracheostomy tube in appropriate position.
2. 1.0 cm left apical pulmonary nodule, given short interval increase in size,
favors a benign process such as inflammation or infection, although short-term
follow-up is recommend.
3. Right greater than left small pleural effusions with associated
atelectasis.
4. Short-term stability of mildly enlarged mediastinal lymph nodes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with goiter, trach, hemoptysis// evaluate
hemoptysis per IP evaluate hemoptysis per IP
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
New left internal jugular line ends in the upper SVC. No attendant
mediastinal widening. Lung volumes remain quite low. Small left pleural
effusion is likely, unchanged. Moderate enlargement of cardiac silhouette is
stable. Bibasilar atelectasis is mild to moderate. No pneumothorax.
Nasogastric drainage tube ends in the stomach. Tracheostomy tube midline.
Radiology Report
INDICATION: ___ year old woman with hemoptysis s/p rigid bronch w biopsy// r/o
PTX
TECHNIQUE: Portable chest x-ray
COMPARISON: Portable chest x-ray ___
FINDINGS:
Lines and supporting devices appear unchanged compared to the previous study.
There are low lung volumes. No pneumothorax is appreciated. There is a small
left effusion, similar to previous. Atelectatic changes persist in the lower
lobes. The heart size is not adequately assessed given the low lung volumes.
The aorta is atherosclerotic and tortuous. The patient's chin obscures the
lung apices. The bones are diffusely osteopenic. Degenerative changes are
evident in the spine.
IMPRESSION:
Low lung volumes with atelectatic changes at the lung bases, and small left
effusion. Findings are similar to the previous study from ___.
Radiology Report
EXAMINATION: CT-guided thyroid mass biopsy.
INDICATION: ___ year old woman with goiter s/p trach, c/f malignancy. CORE
BIOPSY please.
COMPARISON: CT neck ___.
PROCEDURE: CT-guided thyroid mass biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 17 gauge coaxial needle was introduced into the
lesion. An 18 gauge core biopsy device with a 20 mm throw was used to obtain
6 core biopsy specimens, which were sent for pathology.
The specimen was evaluated by onsite cytologist. The more superficial samples
showed adequate tissue sample, but without definite atypia. Deeper samples
showed atypia but evaluation was limited by extensive necrosis. After
multiple intact cores were obtained, a decision was made to stop sampling.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 16.4 cm; CTDIvol = 9.9 mGy (Body) DLP = 149.5
mGy-cm.
2) Stationary Acquisition 11.0 s, 1.4 cm; CTDIvol = 82.9 mGy (Body) DLP =
119.4 mGy-cm.
Total DLP (Body) = 279 mGy-cm.
FINDINGS:
1. Large heterogeneous right thyroid lobe mass is again demonstrated. This
deviates the trachea to the left. Tracheostomy tube is present.
2. Multiple samples were taken from the superficial component of the right
thyroid mass as well as the middle and posterior portions medially along the
tracheal border.
IMPRESSION:
Successful CT-guided thyroid mass biopsy as above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with goiter s/p trach, on heparin gtt with
increasing bloody secretions, intermittently desatting// eval tachypnea, desat
IMPRESSION:
In comparison with the study of ___, there is little change.
Monitoring support devices are stable. Continued low lung volumes with
basilar atelectatic changes and small left effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with goiter s/p trach with worsening resp
status// eval desat eval desat
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Lung volumes remain quite low. Atelectasis has worsened at the left lung
base. Bilateral pleural effusions are likely, but not large. Moderate to
severe cardiomegaly is chronic.
Tracheostomy tip projects over the upper trachea. No pneumothorax or
mediastinal widening.
Left jugular line ends in the low SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p rigid bronch please r/p PTX// r/p PTX
r/p PTX
IMPRESSION:
Compared to chest radiographs ___:
No pneumothorax. Small pleural effusions unchanged. Lung volumes remain
quite low. Moderate to severe cardiomegaly is chronic. No pulmonary edema.
Tracheostomy tube midline. Left central venous catheter ends in the low SVC.
Radiology Report
INDICATION: ___ year old woman with grossly bloody tracheostomy secretions.
Hypoxia to ___. Intrapulmonary hemorrhage.
TECHNIQUE: AP portable semi upright.
COMPARISON: ___ AP chest radiograph
___ chest CT
IMPRESSION:
Patient rotation and low lung volumes limit evaluation. Tracheostomy is again
noted. Left-sided central venous catheter terminates in the region of the
distal SVC, unchanged. No evidence for pneumothorax. Unchanged mild blunting
of bilateral costophrenic angles, compatible with small pleural effusions
versus pleural thickening. Bibasilar atelectasis without evidence for new
consolidation. Cardiomediastinal silhouette is not optimally assessed. Right
upper mediastinal widening was shown to be secondary to right thyroid mass on
prior chest CT. Internal fixation hardware is partially visualized in the
proximal left humerus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Anemia, PE
Diagnosed with Altered mental status, unspecified
temperature: 99.0
heartrate: 120.0
resprate: 22.0
o2sat: 96.0
sbp: 129.0
dbp: 69.0
level of pain: UA
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with hypothyroidism, goiter
since ___, sensorineural hearing loss, morbid obesity and
recent admission ___ for tracheal obstruction and right
vocal cord paralysis secondary to enlarged goiter requiring
tracheostomy, with course complicated by diagnosis of PE/RIJ
DVT/R subclavian DVT discharged on warfarin, who was admitted
___ from her LTACH with hemorrhagic shock from right
iliopsoas/thigh hematoma and HCAP. Her course has been
complicated by pericardial effusion, volume overload, various
clots and bleeding episodes, and diagnosis of anaplastic thyroid
cancer.
Her intermittent desaturation, bloody secretions and air hunger
reflect her thyroid cancer invasion into trachea. Although
radiation therapy in combination with BRAF/MEK inhibitor has not
been fully studied and patient may not be able to tolerate full
course of radiation this would appear to be best trial of
palliation.
#Anaplastic thyroid cancer
Patient has had a goiter for ___ years, and before ___ had
no
full workup per patient and daughter. She presented acutely
___ with
compressive symptoms causing tracheal compression. At that time,
biopsy showed fibrosis and was unrevealing for malignancy.
However, during this hospitalization endocrinology was formally
consulted and repeat biopsy was done; biopsy showed papillary
carcinoma that degenerated into anaplastic cancer. Oncology was
consulted and followed the patient. Radiation oncology was
consulted and said that the risks of radiation outweighed the
benefits. She was BRAF mutation positive and there was
discussion regarding palliative Tafinlar and Mekinist for which
insurance authorization is pending. Palliative care was also
involved in her care and symptom management as below. Transfer
to ___ for additional evaluation
including the role of palliative radiation.
#Acute on chronic respiratory failure secondary to tracheal
obstruction secondary to goiter s/p trach
#Anxiety
#Subjective dyspnea
#Tachypnea
Patient expresses a significant amount of anxiety over trach and
secretions, and often expresses discomfort. She was taken for
two bronchoscopies with IP during this hospitalization, which
showed mass and granulation tissue distal to the trach. Trach
was extended past this on ___, but is temporary as mass is
aggressive and will continue to grow. For symptom management
palliative care was consulted. She was started on standing
klonipin for anxiety control, with Ativan for breakthrough. She
was given duonebs, mucomyst and saline nebulizers with some
improvement in comfort. Morphine 1mg IV q8hrs was also started
for refractory air hunger.
#Hemorrhagic shock
#Right iliopsoas hematoma
#Left bicep hematoma
#Hematuria
#Bloody tracheal secretions
Patient was admitted from her rehab with hemorrhagic shock from
right iliopsoas/pelvic bleed in the setting of being discharged
on warfarin for a RIJ thrombus and PE. She required two ICU
transfers early in her hospital course, with CTAs that did not
show active extravasation or anything intervenable. Heparin gtt
and warfarin were held. She was supported with blood
transfusions, and stabilized. However, throughout her course
whenever challenged with heparin, she developed multiple
bleeding issues: hematuria, left biceps hematoma, and bloody
tracheal secretions from friable mass/granulation tissue.
Decision was made to hold anticoagulation after discussion of
risks/benefits with patient and family.
#Right IJ thrombus
#Left cephalic vein thrombus
#PE
Patient at risk for clots in the setting of malignancy and also
in the setting of compression from goiter. As above, heparin was
trialed multiple times, with bleeding each time.
#HAP
The patient had known tracheal compression s/p trach in setting
of enlarged thyroid. On admission there was also concern for
hospital acquired pneumonia, but breathing also worsened in
setting of acute bleed. She was placed on mechanical ventilation
in the ED for tachypnea, then weaned to pressure support in the
ICU, then to trach mask with appropriate oxygenation. Her CXR
was suggestive of PNA, so she was treated with Zosyn and
vancomycin. Vancomycin was discontinued with MRSA negative swab
and zosyn course completed.
#Pericardial Effusion
Likely malignant. Patient had a small pericardial effusion noted
on ___ prior to this admission. She was found to have fluid
around her pericardium on chest imaging, so TTE was obtained on
___. This showed a moderate pericardial effusion with RV
collapse, consistent with hypovolemia vs tamponade physiology.
Cardiology and cardiac surgery were consulted, who recommended a
repeat TTE. On ___, this showed interval improvement in both
the side of the effusion and lessened RV collapsed. CT surgery
and cardiology recommended no further intervention at this time.
Repeat ___ showed stable effusion.
#Toxic Metabolic Encephalopathy
The patient was supposedly unresponsive with intermittent
twitching at ___ during her entire stay since her
recent discharge ___. CT head with no evidence of intracranial
bleed or abnormality. Neurology was consulted, who recommended
an EEG, which was free from seizure activity and MRI was
considered, however was unable to be performed due to plates in
the patient's arms. Other differentials included thyroid
dysfunction, hypercarbia, electrolyte derangements, and
infection UTI vs PNA. Ultimately, she improved with Zosyn and
vancomycin, while also correcting her anemia which suggested
that her encephalopathy was likely due to infection and toxic
metabolic encephalopathy.
#Vitamin D deficiency
#Hypocalcemia
#Hypothyroidism
Concern that compression from goiter causing hypoparathyroidism
vs surgical disruption of parathyroid glands. Endocrinology
followed her during her course, and she was vitamin D loaded and
then resumed on 1000U daily. Calcium was repleted with feeds and
IV. Levothyroxine was continued at home dosing.
#severe protein calorie malnutrition
Patient had an NGT for feeding at last discharge. She had a PEG
placed during this hospitalization.
#Sinus Tachycardia
At last hospitalization ___ patient was started on
metoprolol for sinus tachycardia. However, sinus tachycardia was
likely compensatory in the setting of PE, malignancy,
respiratory discomfort and anemia. Metoprolol was weaned off.
#Goals of care
The patient experienced a lot of emotional and physical
discomfort during her hospitalization even prior to diagnosis of
anaplastic thyroid cancer. At the time of diagnosis, the
aggressiveness of this cancer was explained and patient and
daughter were very clear that they wanted to seek treatment and
be full code. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodine and Iodide Containing Products / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Thiazides
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Left-sided intrapleural fibrinolysis (___)
Right-sided thoracentesis (___)
History of Present Illness:
Extracted from Admission History and Physical
___ with PMH of HTN, severe AS, moderate MR, Afib on warfarin,
chronic pleural effusion ___ valvular disease s/p L pleural
catheter placement, CKD3/4, who is presenting with erythema and
purulent drainage around pleural catheter site.
Patient was first referred to ___ clinic in ___ for
bilateral L>R pleural effusion. She underwent thoracentesis with
evaluation of sampled fluid and the effusion was eventually
attributed to severe valvular disease. Despite up-titration of
diuretics, she continued to have worsening dyspnea so she
underwent L pleural catheter placement ___ (Dr. ___. After
the procedure, her dyspnea dramatically improved. She was
recently admitted for similar issue from ___ to the
medicine service after she had increasing erythema at pleurex
site and increasing cloudy/bloody drainage. She failed
outpatient
Keflex treatment and was treated for a 13 day course of
initially
vanc/CTX then narrowed to doxycycline/cefpodoxime for
cellulitis.
There was also initially concern for empyema but pleural fluid
analysis seemed more consistent with transudative process and
cultures were negative.
Patient presented to ___ clinic today with worsening shortness of
breath after her pleurex had drained minimal fluid over the last
week. Per notes, IP team was considering pulling pleurex this
week given minimal output over last few weeks and patient was
holding warfarin. On exam, her catheter was foul smelling and
skin surrounding was indurated and erythematous concerning for
cellulitis. Fibrinolytics were instilled in clinic with only 5cc
drained which was sent off for fluid studies. Given concern for
the infection, sent to the ED for further evaluation.
In the ED:
- Initial vital signs were notable for:
T 96.7 HR 64 BP 147/67 RR 18 SpO2 96% RA
- Exam notable for:
Resp: Decreased breath sounds at the bilateral bases R>L. no
respiratory distress. pleurex catheter in place on the left.
CV: RRR, no pedal edema, 2+ distal upper extremity and lower
extremity pulses. Capillary refill <2 sec.
Abd: Soft, Nontender, Nondistended, no rigidity or guarding
Skin: Erythema on the left chest wall surrounding the Pleurx
catheter. Scant seropurulent discharge on the wound dressing. No
fluctuance or discharge expressed.
Neuro: Alert and following commands, moving all extremities
spontaneously, sensation intact to light touch, speech fluent
- Labs were notable for:
WBC 5.7, Cr 1.9.
Pleural fluid: LDH 81, Glucose 109, WBC 460, RBC ___
- Studies performed include:
___ CT Chest w/o contrast:
1. Unchanged catheter position. Small residual pleural
collection
at the base of the left hemithorax, probably organized,
nonspecific although infection cannot be excluded. Small
quantity
of air in the residual pleural collection may be due to catheter
placement; this can perhaps be explained by presence of a
catheter although bronchopleural fistula is not excluded by this
study.
2. Increased, now moderate to large, right-sided pleural
effusion.
3. Persistent substantial chronic atelectasis at each lung base,
left greater than right.
___ CXR:
Left-sided PleurX catheter is unchanged. Bilateral pleural
effusions are moderate volume and are also unchanged.
Cardiomediastinal silhouette is stable. No pneumothorax. The
there is mild pulmonary vascular congestion. There is near
complete atelectasis of both lower lobes left greater than
right,
unchanged.
- Patient was given:
___ 00:15 IV Vancomycin 750 mg
- Consults: IP consulted
Vitals on transfer:
T 98.1 HR 76 BP 138/64 RR 22 SpO2 94% RA
Upon arrival to the floor, patient states she feels fine other
than having worsening shortness of breath with exertion over the
last several weeks. She denies any trouble breathing at rest but
states if she were to get up and walk around she would become
very dyspneic. She otherwise denies any pain at the pleurex
site,
fevers/chills, N/V, or pleurisy."
Past Medical History:
-Chronic bilateral transudative effusions.
-Severe aortic stenosis/moderate mitral regurgitation.
-Paroxysmal atrial fibrillation.
-Chronic kidney disease.
-Iron deficiency anemia.
-Hypertension.
-Hyperlipidemia.
Social History:
___
Family History:
Review and non-contributory for pleural effusion or cellulitis.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VITALS: T 98.1 HR 76 BP 138/64 RR 22 SpO2 94% RA
GENERAL: Alert and interactive
EYES: EOMI. Sclera anicteric and without injection.
ENT: MMM. No JVD.
CARDIAC: Regular rhythm, normal rate. III/VI systolic murmurs at
the RUSB and apex.
RESP: No increased work of breathing. Decreased breath sounds at
the bases bilaterally. Basilar crackles on L. Left chest tube
site with mild surrounding erythema w/o induration. No
tenderness
to palpation.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
palpation
MSK: No spinous process tenderness. No CVA tenderness. No
clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE PHYSICAL EXAM
======================
VITALS: T 97.5, HR 70, BP 120/67, RR 17, O2 95% RA
GENERAL Well appearing elderly female. She occasionally winces
from pain when moving her trunk.
HEENT: Anicteric sclerae. Oropharynx clear.
NECK: JVP estimated at 12 cm.
CV: Regular rate and rhythm. S1/diminished S2. Systolic ejection
murmur. No S3. PMI is not displaced.
PULMONARY: Comfortable. Air movement is fair at bases. There are
residual crackles there as well.
CHEST WALL: There is erythema in the vicinity of the tunneled
pleural catheter insertion site. There is no discharge from the
tract. There is no tenderness or fluctuance.
ABDOMEN: Soft. Non-distended.
EXTREMITIES: Warm. No peripheral edema.
NEURO: Non-focal.
Pertinent Results:
ADMISSION LABS
=============
___ 06:52PM BLOOD WBC-5.7 RBC-3.61* Hgb-10.5* Hct-33.5*
MCV-93 MCH-29.1 MCHC-31.3* RDW-13.6 RDWSD-46.0 Plt ___
___ 06:52PM BLOOD Neuts-76.5* Lymphs-11.0* Monos-10.8
Eos-0.7* Baso-0.5 Im ___ AbsNeut-4.32 AbsLymp-0.62*
AbsMono-0.61 AbsEos-0.04 AbsBaso-0.03
___ 06:52PM BLOOD ___ PTT-35.7 ___
___ 06:52PM BLOOD Glucose-158* UreaN-30* Creat-1.9* Na-135
K-3.7 Cl-97 HCO3-21* AnGap-17
PLEURAL FLUID
============
___ 04:00PM PLEURAL TNC-460* RBC-___* Polys-2* Lymphs-47*
Monos-15* Macro-1* Other-35*
___ 04:00PM PLEURAL TotProt-2.8 Glucose-109 LD(LDH)-81
Cholest-32
___ 10:08AM PLEURAL TNC-110* RBC-201* Polys-16* Lymphs-79*
Monos-4* Meso-1*
___ 10:08AM PLEURAL TotProt-3.3 Glucose-117 LD(LDH)-75
Cholest-39 ___
___ Cytology-Negative for malignant cells
DISCHARGE LABS
==============
___ 05:31AM BLOOD WBC-4.3 RBC-3.46* Hgb-10.0* Hct-31.7*
MCV-92 MCH-28.9 MCHC-31.5* RDW-13.4 RDWSD-44.4 Plt ___
___ 06:35AM BLOOD ___ PTT-37.0* ___
___ 06:35AM BLOOD Glucose-94 UreaN-39* Creat-2.1* Na-139
K-3.9 Cl-99 HCO3-22 AnGap-18
___ 06:35AM BLOOD Calcium-9.3 Phos-4.6* Mg-1.7
___ 06:35AM BLOOD proBNP-5831*
STUDIES
=======
CXR (___)
IMPRESSION:
Left-sided PleurX catheter is unchanged. Bilateral pleural
effusions are
moderate volume and are also unchanged. Cardiomediastinal
silhouette is
stable. No pneumothorax. The there is mild pulmonary vascular
congestion.
There is near complete atelectasis of both lower lobes left
greater than
right, unchanged.
CT CHEST WITHOUT CONTRAST (___)
IMPRESSION:
1. Unchanged catheter position. Small residual pleural
collection at the
base of the left hemithorax, probably organized, nonspecific
although
infection cannot be excluded. Small quantity of air in the
residual pleural
collection may be due to catheter placement; this can perhaps be
explained by
presence of a catheter although bronchopleural fistula is not
excluded by this
study.
2. Increased, now moderate to large, right-sided pleural
effusion.
3. Persistent substantial chronic atelectasis at each lung
base, left greater
than right.
CXR (___)
IMPRESSION:
1. Small bilateral pleural effusions, decreased on the right
status post
thoracentesis. No pneumothorax.
2. Increased moderate pulmonary vascular congestion.
3. Decreased right basilar atelectasis. Unchanged left basilar
atelectasis.
CXR (___)
IMPRESSION:
1. Unchanged small bilateral pleural effusions and pulmonary
vascular
congestion.
2. Unremarkable appearance of the left pleural catheter. No
pneumothorax.
AORTA AND BRANCHES ULTRASOUND (___)
IMPRESSION:
Patent abdominal aorta and common iliac arteries with no
evidence of stenosis.
The abdominal aorta is very tortuous in the setting of severe
atherosclerotic
burden
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Torsemide 30 mg PO DAILY
5. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
DAILY
6. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO TID:PRN Pain
2. Cephalexin 500 mg PO TID
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO BID
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
4. Torsemide 40 mg PO DAILY
5. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral
DAILY
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
-Acute on chronic dyspnea on exertion.
SECONDARY
-Bilateral pleural effusions.
-Tunneled pleural catheter site cellulitis.
-Severe aortic stenosis/moderate mitral regurgitation.
-Stage III/IV chronic kidney disease.
-Paroxysmal atrial fibrillation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pleural effusion s/p ___ on R // s/p
thoracentesis, r/o pneumothorax
TECHNIQUE: Portable AP view of the chest.
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Positioning of the left PleurX catheter is unchanged.
The lungs are well expanded. Left basilar atelectasis is unchanged. Right
basilar atelectasis is decreased. Cardiomediastinal silhouette is moderately
enlarged but unchanged. Moderate pulmonary vascular congestion is increased.
Small left pleural effusion is unchanged. Small right pleural effusion is
decreased, status post thoracentesis. There is no pneumothorax. Spine is
scoliotic.
IMPRESSION:
1. Small bilateral pleural effusions, decreased on the right status post
thoracentesis. No pneumothorax.
2. Increased moderate pulmonary vascular congestion.
3. Decreased right basilar atelectasis. Unchanged left basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ female w bilateral effusions. Exquisite pain in
vicinity of left tunneled pleural catheter. // Pneumothorax.
TECHNIQUE: Chest frontal radiograph
COMPARISON: Multiple priors most recently chest radiograph from ___
FINDINGS:
Left-sided pleural catheter is unchanged. Heart size and mediastinal and
hilar contours are stable. Small bilateral pleural effusions are not
significantly changed. Pulmonary vascular congestion is not significantly
changed. No focal consolidation. No pneumothorax. There is slightly
improved aeration at the left base.
IMPRESSION:
1. Unchanged small bilateral pleural effusions and pulmonary vascular
congestion.
2. Unremarkable appearance of the left pleural catheter. No pneumothorax.
Radiology Report
EXAMINATION: AORTA AND BRANCHES
INDICATION: ___ year old woman with severe aortic stenosis // pre-TAVR
evaluation
TECHNIQUE: Grayscale and color Doppler ultrasound of the abdominal aorta and
common iliac arteries was performed.
COMPARISON: None.
FINDINGS:
The lumen of the aorta measures 2.0 in the proximal portion, 1.8 in mid
portion and 1.9 cm in the distal abdominal aorta. There is severe calcified
atherosclerotic plaque with no evidence of luminal narrowing.
Wall-to-wall color flow is seen within the aorta and common iliac arteries.
The right common iliac artery lumen measures 0.8 and the left common iliac
artery lumen measures 2.7 cm. There is no evidence of luminal narrowing.
The right kidney measures 9.5 cm and the left kidney measures 10.5 cm.
Limited views of the kidneys are unremarkable without hydronephrosis.
IMPRESSION:
Patent abdominal aorta and common iliac arteries with no evidence of stenosis.
The abdominal aorta is very tortuous in the setting of severe atherosclerotic
burden
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Pleural effusion, not elsewhere classified, Cellulitis of chest wall
temperature: 96.7
heartrate: 64.0
resprate: 18.0
o2sat: 96.0
sbp: 147.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ female with chronic bilateral pleural effusions due
to severe aortic stenosis/moderate mitral regurgitation, has a
left-sided tunneled pleural catheter in that regard, referred
for (1) acute on chronic dyspnea on exertion and (2) recurrent
tunneled pleural catheter site cellulitis.
#Acute on chronic dyspnea on exertion due to chronic bilateral
pleural effusions. She underwent thoracentesis for interval
enlargement of the right-sided effusion. Simultaneously, the
intrapleural fibrinolytics instilled via her left-sided tunneled
pleural catheter on the morning she was referred had a delayed
effect, finally draining well here. She was more comfortable and
her ambulatory oxygen saturation was likewise high ninety-range
without supplemental oxygen requirement thereafter. A bedside
ultrasound on the day of discharge was also reassuring. Her TPC
was capped in that regard. Her studies were still consistent
with a transudate. We increased her torsemide to 40 mg daily to
slow the rate of re-accumulation but this is not a long-term
durable solution hence expedite TAVR assessment. Her weight and
NT-pro-BNP at discharge are 125 pounds and 5831, respectively.
#Severe aortic stenosis/moderate mitral regurgitation. She did
not have decompensated heart failure but her valvular disease is
decidedly the cause of her effusions. She was referred to our
structural heart team for TAVR so hoped to expedite that process
this hospitalization; however, renal insufficiency precluded an
elective pre-TAVR coronary angiogram after all. She will have a
low-contrast pre-TAVR CTA after discharge instead. Routine
ultrasound of the aorta and branches was performed. She is
robust for her age and high-risk for re-hospitalization until
the cause of her effusions is addressed so remains a reasonable
candidate for TAVR. She and her family are not opposed to it
either.
#Tunneled pleural catheter site cellulitis. The erythema
receded, and her pleural studies were not consistent with a
secondary infection of the pleural space, so converted
vancomycin to doxycycline/cephalexin. It was once purulent, and
she has been hospitalized for intravenous antibiotics in the
past, so favor both MRSA and Streptococcus spp. coverage.
CHRONIC/STABLE ISSUES
#Paroxysmal atrial fibrillation. She is in normal sinus rhythm
and rate controlled with diltiazem. There are no foreseeable
interventions so resumed warfarin for a CHA2DS2-VASc of 4.
#Stage III/IV chronic kidney disease. Attributed to hypertensive
nephropathy and renovascular disease. Her creatinine of ___ is
in keeping with her trend in the last year.
___ esophagus. Continued omeprazole.
TRANSITIONAL ISSUES
=================
[]Drain left-sided tunnel pleural catheter three times weekly
(i.e., ___.
[]Complete doxycycline/cephalexin for 10-day course of
antibiotics in total.
[]Note torsemide was increased to 40 mg daily. Weight at
discharge is 125 pounds. Adjust accordingly.
[]Repeat BMP within the next week. Consider magnesium supplement
for cramps if hypomagnesemic. Do not administer with
doxycycline.
[]Expedite outpatient TAVR assessment as planned. An appointment
was not secured prior to discharge (___).
[]INR was not yet therapeutic by discharge. Next INR is due
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
peritonitis
Major Surgical or Invasive Procedure:
Peritoneal dialysis catheter removal
Peritoneal dialysis catheter replacement- ___
Tunnelled hemodialysis line placement- ___
Hemodialysis- ___
History of Present Illness:
Mr. ___ is a ___ with a history of ESRD on Peritoneal
Dialysis since ___ who presents as a direct admission from
___ for a recurrent episode of
bacterial peritonitis. The patient reports that approximately 4
weeks ago he began to have symptoms of peritonitis including
abdominal pain. He self treated with cipro for 2 weeks which
initially helped with his symptoms. However his symptoms began
to recur and he developed cloudy peritoneal fluid. He had no
fevers or chills but he did endorse night sweats. No diarrhea,
nausea or vomiting. Yesterday (___) the patient had fluid
drained from his peritoneal catheter which reportedly showed
over 600 WBCs. He was treated with 2 grams of Intraperitoneal
vancomycin.
Of note this is the patient's ___ episode of bacterial
peritonitis. He has had recurrent infections with gram positive
organisms. When he was evaluated by Dr. ___ in transplant
surgery in ___, the plan was to replace his PD catheter if he
develops another episode of peritonitis. Therefore the patient
was admitted to have catheter replaced.
Currently, the patient reports moderate abdominal tenderness but
otherwise has no acute complaints.
ROS: per HPI, denies fever, chills, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, nausea, vomiting, diarrhea, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- ESRD from hypertensive nephropathy on Peritoneal Dialysis
since ___
- HYPOtension, since starting PD the patient's has had frequent
episodes of low BP and had to stop all anti-hypertensives. His
nephrologist has him on a high sodium diet.
- Morbid Obesity. Previously weighed over 350 pounds but now
down to 250.
Social History:
___
Family History:
No inherited renal disease
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS - Temp 97.7F, BP 118/66 , HR 80 , R20 , 97% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - moderate diffuse tenderness. No rebound or guarding.
Peritoneal catheter site clean with dressing intact. No
surrounding erythema.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout. Gait not
assessed
PHYSICAL EXAM ON DISCHARGE:
VS - Temp 99.4F, BP 135/85 , HR 90 , R17 , 97% RA
ABDOMEN: old PD catheter dc'd and a new one is placed. Mild
diffuse tenderness, no rebound or guarding
Pertinent Results:
___ 03:20PM BLOOD WBC-7.8 RBC-2.66* Hgb-8.8* Hct-25.7*
MCV-97 MCH-33.1* MCHC-34.1 RDW-16.2* Plt ___
___ 06:36AM BLOOD WBC-9.2 RBC-2.53* Hgb-7.9* Hct-24.1*
MCV-95 MCH-31.4 MCHC-32.9 RDW-15.9* Plt ___
___ 03:20PM BLOOD ___ PTT-37.7* ___
___ 03:20PM BLOOD Glucose-73 UreaN-80* Creat-24.3* Na-139
K-4.4 Cl-96 HCO3-23 AnGap-24*
___ 06:00AM BLOOD Glucose-113* UreaN-79* Creat-23.4* Na-137
K-4.0 Cl-94* HCO3-26 AnGap-21*
___ 06:30AM BLOOD Glucose-81 UreaN-87* Creat-28.1*# Na-140
K-4.6 Cl-98 HCO3-26 AnGap-21*
___ 06:35AM BLOOD Glucose-87 UreaN-91* Creat-29.5*# Na-139
K-4.6 Cl-97 HCO3-23 AnGap-24*
___ 06:00AM BLOOD Glucose-89 UreaN-101* Creat-32.1*# Na-139
K-4.9 Cl-97 HCO3-26 AnGap-21*
___ 06:10AM BLOOD Glucose-88 UreaN-107* Creat-33.9*# Na-139
K-5.5* Cl-97 HCO3-25 AnGap-23*
___ 06:25AM BLOOD Glucose-71 UreaN-112* Creat-35.2*# Na-138
K-5.3* Cl-98 HCO3-23 AnGap-22*
___ 05:40PM BLOOD Na-136 K-5.3* Cl-95*
___ 09:52PM BLOOD Na-137 K-5.2* Cl-94*
___ 06:20AM BLOOD Glucose-79 UreaN-117* Creat-36.5*# Na-139
K-5.0 Cl-96 HCO3-23 AnGap-25*
___ 06:36AM BLOOD Glucose-69* UreaN-119* Creat-38.0*#
Na-135 K-4.5 Cl-93* HCO3-21* AnGap-26*
___ 03:20PM BLOOD ALT-10 AST-11 LD(LDH)-119 AlkPhos-50
TotBili-0.4
___ 03:20PM BLOOD Lipase-29
___ 03:20PM BLOOD Albumin-3.4* Calcium-8.0* Phos-10.5*
Mg-2.1
___ 06:36AM BLOOD Calcium-8.3* Phos-8.7* Mg-2.3
___ 06:00AM BLOOD PTH-996*
___ 06:36AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
___ 03:20PM BLOOD Vanco-19.6
___ 06:10AM BLOOD Vanco-18.9
___ 06:30AM BLOOD Vanco-16.0
___ 06:00AM BLOOD Vanco-19.9
___ 06:10AM BLOOD Vanco-22.8*
___ 06:25AM BLOOD Vanco-19.1
___ 06:20AM BLOOD Vanco-19.5
___ 06:36AM BLOOD Vanco-18.5
___ 06:36AM BLOOD HCV Ab-PND
___ 02:30PM URINE Color-Straw Appear-Hazy Sp ___
___ 02:30PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
___ 02:30PM URINE RBC-70* WBC-9* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
___ 02:30PM URINE Mucous-RARE
___ 3:00 pm URINE Source: ___.
URINE CULTURE (Pending):
___ 5:22 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Reported to and read back by ___ ___ AT
1217.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Peritoneal fluid cytology (___)
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, macrophages, lymphocytes and
numerous neutrophils.
Abdominal X-ray (___)
IMPRESSION: PD catheter is curled within the pelvis. Mild ileus.
Tunnelled HD line placement (___)- prelim
1. Placement of a tunneled hemodialysis line into the right
atrium via the right internal jugular vein under ultrasound and
fluoroscopic visualization.
2. The line is ready to use.
Lab Results on Discharge:
___ 06:40AM BLOOD WBC-7.2 RBC-2.40* Hgb-7.3* Hct-23.5*
MCV-98 MCH-30.6 MCHC-31.2 RDW-15.8* Plt ___
___ 06:40AM BLOOD Glucose-90 UreaN-71* Creat-24.0*# Na-138
K-4.3 Cl-100 HCO3-24 AnGap-18
___ 06:40AM BLOOD Calcium-8.7 Phos-7.1* Mg-2.2
___ 06:40AM BLOOD Vanco-20.4*
___ 06:36AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
___ 06:36AM BLOOD HCV Ab-PND
Medications on Admission:
vancomycin dosed ___ IP
allopurinol ___
asa 81mg daily
calcium acetate 667 tid w meals
cinecalcet 90mg qdinner
calciferol 2.5mcg 2 capsules daily (5mcg daily)
ferrous gluconate 324mg tid
lactulose 60cc prn constipation
prn senna
miralax 17gm daily
sevelamer (800mg tablets) 5 tablets tid with meals, and 2
tablets
with snacks
simvastatin 20mg hs
dilavite vitamin b complex daily
epogen ___ units once weekly sq
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. vancomycin 1,000 mg Recon Soln Sig: One (1) bag Intravenous
with HD: please dose by vancomycin level. With HD.
4. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
6. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q8H (every 8 hours)
as needed for pain: hold for sedation, RR < 12.
7. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
twice a day as needed for constipation.
8. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation: hold for loose stools.
11. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO Q8H
(every 8 hours) as needed for constipation.
12. Epogen 2,000 unit/mL Solution Sig: One (1) injection
Injection once a week.
13. sevelamer carbonate 800 mg Tablet Sig: Five (5) Tablet PO
three times a day: with meals, 2 tabs with snacks.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Medicine
IV iron with hemodialysis
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary- Peritonitis
ESRD- initiated hemodialysis
Secondary- History of hypertension prior to initiation of PD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ gentleman with end-stage renal disease, bacterial
peritonitis, status post replacement of peritoneal catheter, now starting PD
dialysis with no return of fluid exchange, assess location of tip.
FINDINGS: Upright and supine abdominal radiographs reveal a catheter entering
the left lower quadrant and curling dependently within the pelvis, likely
reflecting the peritoneal dialysis catheter. Prominent small and large bowel
loops are seen with mild dilatation in air-fluid levels in small bowel,
possibly reflecting mild ileus with air and stool seen in the colon and
rectum. Centralization of bowel loops may reflect ascites. Imaged lung bases
are unremarkable.
IMPRESSION: PD catheter is curled within the pelvis. Mild ileus.
Radiology Report
TUNNELED HEMODIALYSIS LINE PLACEMENT
CLINICAL INDICATION: ___ man with end-stage renal disease on
peritoneal dialysis, failing the use of new peritoneal dialysis catheter,
needs tunneled hemodialysis line.
Informed consent for the procedure was obtained after risks, benefits, and
potential complications had been discussed. The patient was placed on the
angiographic table in supine position and the skin of the right anterior neck
and right anterior chest wall was prepped and draped in a sterile fashion.
Timeout protocol was carried out prior to the procedure according to the ___
___ policy.
PHYSICIANS: ___ MD ___ MD (___) and
___ MD ___ physician).
ANESTHESIA: Local, 1% lidocaine.
MONITORED CONSCIOUS SEDATION: The procedure was performed under monitored
conscious sedation. The patient received a total quantity of 1 mg of Versed
and 100 mcg of fentanyl intravenously during the procedural time of 21
minutes, while his hemodynamic parameters and pulse oximetry were continually
monitored by trained radiology nurse.
After generous infiltration of the subcutaneous soft tissues by 1% lidocaine,
and under real-time ultrasound guidance, the patent and fully compressible
right internal jugular vein was punctured using 21-gauge micropuncture needle.
Over a 0.018 guide wire, micropuncture needle was exchanged for a 4 ___
micropuncture sheath. A 0.035 ___ guide wire was then advanced through the
4 ___ micropuncture sheath into the right atrium and prospective length of
a tunneled hemodialysis line was calculated. ___ guide wire was
subsequently reintroduced into the right atrium and advanced into the inferior
vena cava. The attention was then diverted to the right anterior chest wall.
After generous infiltration of subcutaneous soft tissues by 1% lidocaine
without and with epinephrine, a narrow skin incision was made inferior and
lateral to the right internal jugular venipuncture. A soft tissue tunnel was
created by blunt dissection between the chest wall incision and right internal
jugular venipuncture. A new 24-cm long 14 ___ hemodialysis catheter was
then pulled through the tunnel. After appropriate dilatation of the needle
tract, the tip of the catheter was advanced into the right atrium through the
appropriate peel-away sheath which was subsequently removed. Right internal
jugular venipuncture was sutured using 4.0 Vicryl suture. The hemodialysis
catheter was secured to the skin outside the tunnel using 0 silk sutures and
covered with sterile dressing.
Dr. ___, the attending physician, supervised this interventional
procedure.
CONCLUSION:
1. Placement of a tunneled hemodialysis line into the right atrium via the
right internal jugular vein under ultrasound and fluoroscopic visualization.
2. The line is ready to use.
Gender: M
Race: BLACK/AFRICAN
Arrive by UNKNOWN
Chief complaint: PERITIONITIS
Diagnosed with END STAGE RENAL DISEASE
temperature: 98.6
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 144.0
dbp: 81.0
level of pain: 5
level of acuity: 3.0 | PRIMARY REASON FOR HOSPITALIZATION:
Mr. ___ is a ___ with a history of ESRD on Peritoneal
Dialysis since ___ who presented as a direct admission from
___ for a recurrent episode of
bacterial peritonitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hydrochlorothiazide / contrast dye
Attending: ___.
Chief Complaint:
Low back pain
Major Surgical or Invasive Procedure:
Spinal Decompression Surgery ___
- Laminectomy L1-L2, L2-L3, L3-L4
- Far-lateral decompression, L4-5 procedure
- Laminectomy L5-S1
Coronary Cath ___
History of Present Illness:
Mr. ___ is a ___ with a history of CHF, CAD s/p DES
in and RCA, and DMII presenting with low back pain. Per ED,
patient states that he has had worsening low back pain over the
past month but over the past few days has had multiple episodes
of loss of bladder or bowel control. Associated with multiple
falls he states the falls are secondary to his legs giving out
from underneath him because of weakness. He does use a walker at
home. He denies fevers chills chest pain shortness of breath or
abdominal pain. He denies saddle anesthesia history of IV drug
abuse. Upon arrival to the floor pt clarifies that about 1 month
ago, he went to sit on the toilet seat, slipped, and fell to the
floor. He experienced difficulty walking and R side low back
pain after falling. For the past ___ weeks, he has experienced
bowel and bladder incontinence and has noticed that his hands
fall asleep at night. He has had 15 additional falls over the
past month. He denies saddle anesthesia. Prior to fall, he was
ambulating with a walker and could walk about 1 block with his
walker before getting SOB. Recently, for the past month, he
notes increased SOB while ambulating, can only walk from bed to
hall before getting SOB. Associated cough with sputum
production.
In the ED, VS T 96.39, HR 74, BP 133/66, RR 19, O2 99% RA.
Physical exam was notable for ___ strength and normal sensation
in bilateral lower extremities, normal rectal tone, and
tenderness to palpation over L4. ED labs reviewed and notable
for urine and serum tox negative, UA negative, Cr 1.8, WBC 10.2,
Hgb 8.8, INR 1.2. Code cord was called after imaging revealed
radiographic findings concerning for cord compression.
Spine was consulted and noted that patient would likely need
decompressive surgery for symptoms and narrowing at multiple
levels of the lumbar spine, however, recommend cardiology and
medical optimization prior to surgery. ___ was also consulted and
is following.
Past Medical History:
- Asthma
- CHF
- CAD s/p DES x2- Proximal LAD and Distal RCA
-DM II complicated by diabetic nephropathy
- Hyperlipidemia
- Hypertension
- Osteoarthritis
- Prostate cancer
- Eczema
- CKD
- Anemia of chronic disease
Social History:
___
Family History:
Father died due to epilepsy. Mother died due to a stroke. No
early CAD or sudden cardiac death. Daughter has RA.
Physical Exam:
==================================
Physical Examination on admission:
==================================
VS: T 98.0 BP 149/62 HR 71 RR 18 O2 96% Ra
GENERAL: Alert, in NAD, resting comfortably in bed
HEENT: NC/AT, EOMI, PEERL, MMM, dentures
NECK: Supple, non-tender, no LAD
HEART: RRR, normal S1/S2, no JVD, no m/r/g
LUNGS: Mildly prolonged expiratory phase, otherwise CTAB,
breathing comfortably without use of accessory muscles
ABDOMEN: Soft, non-tender to palpation, + bowel sounds
GU: no foley
EXTREMITIES: No cyanosis or clubbing, no ___ edema
SKIN: Multiple ecchymoses in ___ upper extremities, dry, flaky
skin on ___ lower extremities, warm and well perfused
NEURO: CN II-XII grossly intact, ___ strength in upper
extremities, markedly reduced strength to dorsiflexion in L hip
(___) and foot (___), intact sensation in ___ lower extremities,
negative Babinski ___
==================================
Physical Examination on discharge:
==================================
VITALS: Tm 98.3 BP 153/60 HR 63 RR 18 SPO2 100% RA
PHYSICAL EXAM:
General: Sitting up in bed, in NAD, interacting appropriately
HEENT: MMM
Cardio: RRR. Nl s1/s2. No m/r/g.
Pulm: Lungs clear. No wheezes or rhonchi. good air movement
Abdomen: soft, non-tender, non-distended, normoactive BS
GU: Foley in place.
Ext: Trace ___ edema
Back: Dressing in place
Skin: Warm and well-perfused perfused
Neuro: AAOx3. Strength 4+/5 in hip flexion bilaterally. ___
left
plantar flexion, ___ left dorsiflexion. ___ right plantar
flexion
___ right dorsiflexion; largely unchanged. Patient has a
difficult time every day with ankle flexion/extension
Pertinent Results:
===============
Admission labs
===============
___ 03:23PM WBC-10.2* RBC-3.58* HGB-8.8* HCT-29.5*
MCV-82# MCH-24.6* MCHC-29.8* RDW-14.9 RDWSD-44.6
___ 03:23PM ALT(SGPT)-9 AST(SGOT)-24 ALK PHOS-82 TOT
BILI-0.3
___ 03:23PM GLUCOSE-83 UREA N-31* CREAT-1.8* SODIUM-138
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-21* ANION GAP-19*
=======================
Pertinent interval labs
=======================
___ 06:10PM BLOOD WBC-8.4 RBC-3.15* Hgb-7.8* Hct-25.9*
MCV-82 MCH-24.8* MCHC-30.1* RDW-15.1 RDWSD-45.2 Plt ___
___ 11:57PM BLOOD WBC-12.8* RBC-3.08* Hgb-7.6* Hct-26.2*
MCV-85 MCH-24.7* MCHC-29.0* RDW-15.3 RDWSD-47.2* Plt ___
___ 07:20AM BLOOD WBC-17.3* RBC-3.30* Hgb-8.6* Hct-28.5*
MCV-86 MCH-26.1 MCHC-30.2* RDW-15.4 RDWSD-48.3* Plt ___
___ 03:30AM BLOOD WBC-10.5* RBC-3.09* Hgb-8.1* Hct-25.6*
MCV-83 MCH-26.2 MCHC-31.6* RDW-15.4 RDWSD-46.5* Plt ___
___ 05:20AM BLOOD ___ PTT-26.3 ___
___ 06:10PM BLOOD Glucose-163* UreaN-26* Creat-1.5* Na-137
K-4.5 Cl-102 HCO3-23 AnGap-12
___ 07:20AM BLOOD Glucose-230* UreaN-33* Creat-2.0* Na-142
K-5.4* Cl-102 HCO3-16* AnGap-24___ 01:20PM BLOOD Glucose-277* UreaN-38* Creat-2.1* Na-136
K-4.6 Cl-100 HCO3-20* AnGap-16
___ 06:52AM BLOOD Glucose-135* UreaN-40* Creat-2.2* Na-136
K-4.3 Cl-101 HCO3-20* AnGap-15
___ 03:30AM BLOOD Glucose-141* UreaN-37* Creat-1.8* Na-134
K-5.0 Cl-102 HCO3-20* AnGap-12
___ 07:20AM BLOOD Albumin-2.8* Calcium-7.8* Phos-5.4*
___ 01:20PM BLOOD Calcium-7.3* Phos-4.5 Mg-1.7
___ 03:30AM BLOOD WBC-10.5* RBC-3.09* Hgb-8.1* Hct-25.6*
MCV-83 MCH-26.2 MCHC-31.6* RDW-15.4 RDWSD-46.5* Plt ___
___ 07:05AM BLOOD WBC-9.8 RBC-3.30* Hgb-8.5* Hct-27.4*
MCV-83 MCH-25.8* MCHC-31.0* RDW-15.9* RDWSD-47.7* Plt ___
___ 03:30AM BLOOD Glucose-141* UreaN-37* Creat-1.8* Na-134
K-5.0 Cl-102 HCO3-20* AnGap-12
___ 07:05AM BLOOD Glucose-109* UreaN-28* Creat-1.2 Na-139
K-4.7 Cl-104 HCO3-21* AnGap-14
___ 07:05AM BLOOD cTropnT-0.11*
___ 07:56PM BLOOD cTropnT-0.09*
___ 06:15AM BLOOD Glucose-179* UreaN-24* Creat-1.1 Na-140
K-4.5 Cl-105 HCO3-21* AnGap-14
___ 06:15AM BLOOD cTropnT-0.09*
___ 07:00AM BLOOD WBC-8.9 RBC-3.24* Hgb-8.2* Hct-27.0*
MCV-83 MCH-25.3* MCHC-30.4* RDW-15.9* RDWSD-48.6* Plt ___
___ 07:00AM BLOOD Glucose-129* UreaN-14 Creat-0.9 Na-139
K-4.6 Cl-105 HCO3-21* AnGap-13
===============
Discharge labs
===============
___ 07:20AM BLOOD WBC-9.0 RBC-3.28* Hgb-8.4* Hct-27.5*
MCV-84 MCH-25.6* MCHC-30.5* RDW-16.0* RDWSD-49.3* Plt ___
___ 07:20AM BLOOD Glucose-163* UreaN-14 Creat-1.0 Na-140
K-5.0 Cl-105 HCO3-18* AnGap-17*
___ 01:10AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:10AM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:10AM URINE RBC-6* WBC-42* Bacteri-FEW* Yeast-NONE
Epi-<1
===============
Studies
===============
Pharmacologic stress test (___): The image quality is adequate
but limited due to soft tissue and left arm attenuation. There
is motion. Left ventricular cavity size is increased. Rest and
stress perfusion images reveal a partially reversible, severe
reduction in photon counts involving the entire inferior wall.
Gated images reveal hypokinesis of the basal inferior wall. The
calculated left ventricular ejection fraction is 44% with an EDV
of 160 ml. IMPRESSION: 1. Partially reversible, medium sized,
severe perfusion defect involving the RCA territory. 2.
Increased left ventricular cavity size. Mild systolic
dysfunction with hypokinesis of the basal inferior wall.
CXR (___): IMPRESSION: Increased patchy opacities at both lung
bases may reflect atelectasis or aspiration/pneumonia.
CARDIAC CATH (___): Impressions: 1. Calcific two vessel
coronary artery disease with patent prior drug-eluting stents,
progression of disease in the mid LAD, new severe heavily
calcified ostial RCA disease (likely with contribution from
guiding catheter trauma from prior PCI) and moderate
proximal-edge restenosis in a hyperdominant RCA. 2. Systemic
systolic arterial hypertension
with wide aortic pulse pressure. 3. Normal average left
ventricular end diastolic pressure.
L-spine XR (___): IMPRESSION: Degenerative changes. With
intervertebral disc space narrowing at all lumbar levels.
CT head without contrast (___): IMPRESSION: 1. No acute
intracranial abnormalities. 2. Chronic microangiopathy and age
related global atrophy.
MRI spine w/o contrast (___): 1. Severe spondylotic changes
of the lumbar spine most prominent from at L2-3 and L3-4 where
there is severe spinal canal stenosis resulting redundancy of
the cauda equina nerve roots superiorly. There is multilevel
severe neural foraminal narrowing as detailed above. 2.
Compression deformity of the T12 vertebral body with signal
characteristics indicating possible acute to subacute stage.
Consider further evaluation with a CT lumbar spine for better
evaluation of bony detail.
CT spine w/o contrast (___): 1. Mild anterolisthesis of the
of C4 on C5 and C7 on T1 is likely degenerative in etiology. No
acute fracture identified. 2. Extensive degenerative changes of
the cervical spine with multilevel moderate vertebral canal and
multilevel severe neural foraminal stenosis, as described above.
3. Mottled appearance of the bone may be related to
osteoporosis. However, correlation with history of malignancy
is recommended. If there is clinical concern, a nonemergent
bone scan can be obtained for further evaluation.
===============
Microbiology
===============
Urine culture (___): pending
Blood culture (___): Negative
Stool studies (___): Negative for campylobacter, c. diff
Urine culture (___): No growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
___
2. Pulmicort (budesonide) 180 mcg inhalation BID
3. Bumetanide 1 mg PO DAILY
4. GlipiZIDE 10 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 40 mg PO QPM
10. TraMADol 50 mg PO Q8H
11. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Give no more than 4g per day
RX *acetaminophen 500 mg 2 capsule(s) by mouth every six (6)
hours Disp #*240 Capsule Refills:*0
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth q24h Disp #*30 Tablet
Refills:*0
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet
Refills:*0
4. Cefpodoxime Proxetil 200 mg PO ONCE Duration: 1 Dose
To be given on ___ at ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*2 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % q24h Disp #*30 Patch Refills:*0
7. Senna 8.6 mg PO BID constipation
8. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
Stop date: ___. Aspirin 81 mg PO DAILY
10. Bumetanide 1 mg PO DAILY
11. GlipiZIDE 10 mg PO BID
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Omeprazole 20 mg PO DAILY
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
___
16. Pulmicort (budesonide) 180 mcg inhalation BID
17. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you see your
primary care provider
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
#Cauda Equina Syndrome/Cord Compression
#Type I NSTEMI
#CAP
#Delirium
#Urinary tract infection
Secondary Diagnosis:
#HFrEF
#Acute Kidney Injury
#Anion gap metabolic acidosis
#Type 2 diabetes mellitus
#Acute on chronic anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with weakness// eval for PNA
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Cardiac silhouette is mildly enlarged as on prior. The lungs are clear
besides mild left basilar atelectasis. There is no edema nor effusion. No
acute osseous abnormalities.
IMPRESSION:
Cardiomegaly without superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE.
INDICATION: History: ___ with with atraumatic back pain associated with
urinary and bowel incontinenceIV contrast to be given at radiologist
discretion as clinically needed// eval for cauda equina
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: CT lumbar spine ___.
FINDINGS:
The study is partially degraded due to motion.
There is mild broad-base convex-right curvature of the lumbar spine and a
slight retrolisthesis at L1-L2. There is approximately 25% height loss of the
T12 vertebral body demonstrating central T1/T2 linear low signal and
superimposed surrounding T2 hyperintensity possibly reflecting acute to
subacute fracture pathology. There are superimposed multilevel degenerative
endplate changes and marginal osteophytes. Multilevel disc space narrowing is
most prominent from L2-3 through L4-5. Multilevel moderate to severe spinal
canal stenosis as detailed below results in clumping of the cauda equina nerve
roots at L1-2. There is no cord signal abnormality. The conus medullaris
terminates normally at the level of L1. No evidence of infection or neoplasm.
T11-12: Ligamentum flavum hypertrophy and facet arthropathy results in
mild-to-moderate bilateral neural foraminal narrowing and mild spinal canal
stenosis.
T12-L1: Ligamentum flavum hypertrophy and facet arthropathy with
mild-to-moderate bilateral neural foraminal narrowing and mild spinal canal
stenosis.
L1-2: Diffuse disc bulging, a slight retrolisthesis, ligamentum flavum
hypertrophy and facet arthropathy result in moderate to severe spinal canal
stenosis, severe right and severe left neural foraminal narrowing.
L2-3: Diffuse disc bulging, ligamentum flavum hypertrophy and facet
arthropathy result in severe spinal canal stenosis, moderate to severe right
and moderate to severe left neural foraminal narrowing, as well as crowding of
the nerve roots within thecal sac.
L3-4: Diffuse disc bulging, ligamentum flavum hypertrophy and facet
arthropathy result in severe spinal canal stenosis, moderate right and
moderate to severe left neural foraminal narrowing.
L4-5: Diffuse disc bulging, ligamentum flavum hypertrophy and facet
arthropathy result in moderate to severe spinal canal stenosis, moderate to
severe right and severe left neural foraminal narrowing.
L5-S1: Diffuse disc bulging results an mild spinal canal stenosis, moderate to
severe right and moderate left neural foraminal narrowing.
Other:
The right kidney is mildly atrophic relative to the left.
IMPRESSION:
1. Severe spondylotic changes of the lumbar spine most prominent from at L2-3
and L3-4 where there is severe spinal canal stenosis resulting redundancy of
the cauda equina nerve roots superiorly. There is multilevel severe neural
foraminal narrowing as detailed above.
2. Compression deformity of the T12 vertebral body with signal characteristics
indicating possible acute to subacute stage. Consider further evaluation with
a CT lumbar spine for better evaluation of bony detail.
NOTIFICATION: The primary team was aware of these findings at the time of
this interpretation.
Additional the findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:18 am, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with history multiple falls// eval for bleed eval
for c-spine fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 20.0 s, 20.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
1,003.4 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes. Ill-defined periventricular
subcortical white matter hypodensities are nonspecific but likely due to small
vessel ischemic disease. Mild atherosclerotic calcifications are seen in
bilateral carotid siphons.
There is no evidence of fracture. Mild mucosal thickening is seen in the
maxillary sinuses, left greater than right, with hyperostosis of the sinus
walls suggesting chronic inflammation. Otherwise, the remaining visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Patient is status post bilateral lens resections. A superficial
1.2 x 1.8 cm soft tissue lesion is seen in the base of the left occiput,
likely sebaceous cyst.
IMPRESSION:
1. No acute intracranial abnormalities.
2. Chronic microangiopathy and age related global atrophy.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with history multiple falls// eval for bleed eval
for c-spine fracture eval for bleed eval for c-spine fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 23.5 cm; CTDIvol = 22.8 mGy (Body) DLP = 536.2
mGy-cm.
Total DLP (Body) = 536 mGy-cm.
COMPARISON: No relevant comparison exams.
FINDINGS:
There is mild anterolisthesis of C4 on C5 and C7 on T1, likely degenerative in
etiology. No acute fractures are identified. There is no prevertebral soft
tissue edema. Extensive degenerative changes are seen throughout the cervical
spine with fusion of the C5-C6 vertebral level, loss of intervertebral disc
height, subchondral sclerosis, and extensive osteophyte formation.
There is a mottled appearance of the osseous structures diffusely with
multiple small rounded lucencies, possibly related to osteoporosis. There is
multilevel moderate vertebral canal narrowing due to posterior osteophyte and
disc bulges with deformation of the spinal cord, most pronounced at C3-4, C5-6
and C6-7. Multilevel uncovertebral and facet joint hypertrophy causes severe
neural foraminal stenosis at the left C3-C4, left C4-C5, right C5-C6 and right
C6-C7 vertebral levels. There is no evidence of infection or neoplasm.
The visualized thyroid gland is unremarkable. Emphysematous changes are seen
in the lung apices.
IMPRESSION:
1. Mild anterolisthesis of the of C4 on C5 and C7 on T1 is likely degenerative
in etiology. No acute fracture identified.
2. Extensive degenerative changes of the cervical spine with multilevel
moderate vertebral canal and multilevel severe neural foraminal stenosis, as
described above.
3. Mottled appearance of the bone may be related to osteoporosis. However,
correlation with history of malignancy is recommended. If there is clinical
concern, a nonemergent bone scan can be obtained for further evaluation.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old man with severe lumbar spinal stenosis// pre op
planning, eval for spondylolisthesis. STANDING FLEX EX FILMS pre op
planning, eval for spondylolisthesis. STANDING FLEX EX FILMS
TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine.
COMPARISON: CT scan lumbar spine from ___. MRI of the lumbar
spine from ___.
FINDINGS:
The bone is a diffusely osteopenic. There is mild dextroscoliosis of the
lumbar spine. There is mild retrolisthesis of L1 on L2 and L2 on L3.
Intervertebral disc space narrowing is seen at all lumbar levels. There is a
fracture of the T12 vertebral body with approximately 50% loss of height,
unchanged compared to the recent MRI. Severe degenerative changes are seen at
all lumbar levels.
Vascular calcification is evident.
IMPRESSION:
Degenerative changes. With intervertebral disc space narrowing at all lumbar
levels.
Radiology Report
EXAMINATION: Intraoperative radiograph
INDICATION: ___ man with laminectomy.
TECHNIQUE: Single view of the lumbar spine in the OR.
COMPARISON: Radiographs from ___ MRI from ___
FINDINGS:
1 intraoperative image was acquired without a radiologist present during an
invasive procedure. Multiple hardware projects over the posterior elements of
the lumbar spine. Severe degenerative changes of the lumbar spine is better
evaluated on the prior MRI from ___.
IMPRESSION:
Intraoperative images were obtained during invasive procedure without a
radiologist present. Please refer to the operative note for details of the
procedure.
Radiology Report
INDICATION: ___ year old man with CAD, CHF, type II DM, and recent
decompression of lumbar spine now with productive cough// r/o PNA
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Increased patchy opacities at both lung bases may reflect atelectasis or
aspiration/pneumonia. No pleural effusion or pneumothorax is identified. The
size of the cardiac silhouette is mildly enlarged, similar to prior.
IMPRESSION:
Increased patchy opacities at both lung bases may reflect atelectasis or
aspiration/pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lower back pain, Urinary incontinence
Diagnosed with Low back pain
temperature: 96.39
heartrate: 74.0
resprate: 19.0
o2sat: 99.0
sbp: 133.0
dbp: 66.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is an ___ man with a history of CHF, CAD,
DMII, and a remote history of prostate cancer who presented
after a fall one week PTA with new bowel incontinence, now s/p
cardiac catheterization and spinal decompression ___.
===============================
Acute medical issues addressed
===============================
# Back pain ___ cord compression: Patient diagnosed with cord
compression (cauda equina) on CT and MRI of the spine and had
fecal incontinence and lower extremity weakness. Patient
underwent L1-S1 laminectomy evening ___. His post-op pain
was managed with scheduled Tylenol, prn Tramadol initially, and
lidocaine patch. ___ worked with him during admission. Patient
initially had a foley post-op and had issues with some urinary
retention post-op despite an intact neurologic exam and had to
be straight cathed. Due to ongoing urinary retention, a foley
was placed on ___. On discharge, he had some weakness in his
lower extremities still as described in his discharge physical
exam. He will need to have a voiding trial at rehab but likely
has permanent damage from his cauda equina. If there continue
to be ongoing urinary retention issues, patient should have
urology follow-up scheduled as an outpatient.
#NSTEMI in setting of HFrEF (EF 45% in ___ and prior PCI in
___ of proximal LAD and distal RCA. Patient underwent cardiac
catheterization on ___ prior to laminectomy with two stenotic
coronary vessels. Given need for urgent spinal decompression,
decision was made not to place bare metal stents due to concern
for dual antiplatelet therapy during surgery. Patient did not
undergo POBA. Patient was treated with atorvastatin 80 mg PO
daily, ASA 81 mg PO daily, amlodipine 10 mg PO daily for BP
control, metoprolol 6.25 mg PO q6h. His Bumex was initially held
in setting of ___. He was given nitroglycerin available PRN
chest pain. On ___, he was cleared for any future DAPT.
Cardiology was reconsulted who recommended repeat EKG and trops.
Trops were elevated (0.11), which they felt was from his
catheterization. These were trended and they went down. Repeat
EKG was unchanged and patient was asymptomatic. Pharmacologic
stress testing was done on ___ which showed partially
reversible, medium sized, severe perfusion defect involving the
RCA territory. However, due to the fact that the patient was
asymptomatic, the decision was made by Cardiology not to do an
interventional procedures and instead treat the patient
medically. Bumex 1 mg PO daily was restarted on ___ for crackles
on exam and ___ edema. His losartan was held due to initial ___.
#Concern for CAP. Patient with new productive cough and
bilateral infiltrates on
CXR concerning for PNA. However, patient afebrile and without
leukocytosis. The decision was made to treat the patient for
community acquired pneumonia as he was so stable. He was given
azithromycin for 5 days and ceftriaxone, later transitioned to
cefpodoxime for his outpatient treatment for a total of 7 days.
He will require one day of cefpodoxime 200 mg PO q12h while at
rehab (stop date ___.
___, likely prerenal in the setting of two interventional
procedures and getting IV contrast. Cr peaked at 2.2. Spun urine
showed sediment/casts which showed granular casts only. He was
given prn IVF and his Bumex was held initially. His Cr improved
and was 1.0 on discharge. His losartan was held due to initial
___.
#Acute on chronic normocytic anemia: Patient's Hgb dropped to
6.9 ___ from 7.6 and 8.6, thought to be ___ intraoperative
losses. He was given 1 unit PRBCs ___ with appropriate bump
in his hemoglobin. His H&H stayed stable throughout his
admission. He should have further outpatient workup of his
anemia.
#Elevated anion gap metabolic acidosis: Resolved. Patient
acidemic on ABG found to be a primary metabolic acidosis with a
slight superimposed respiratory acidosis, which resolved with
IVF. However, he later developed a mild non-gap metabolic
acidosis of unclear etiology. Would continue to trend
electrolytes at rehab.
#Delirium. Patient saying some non-sensical statements
throughout hospital course and was not sleeping well at night.
Likely multifactorial ___ PNA, spinal surgery, and urinary
retention. Patient was never agitated and delirium has been
improving, especially with treatment of PNA and after placement
of foley.
#UTI
Patient with worsening delirium on ___. UA checked which was
positive for 42 WBCs, few bacteria, and large leukocyte
esterase. He was started on Bactrim DS 1 tab BID for a total of
7 days (stop date: ___. Urine culture was pending on
discharge.
#Thrombocytosis
Plts increased >400k starting ___, most likely ___ UTI, 538k on
day of discharge, may continue to trend.
# DM II with recent hypoglycemic episode. Last HbA1c 6.3% on
___. Patient was given low dose sliding scale insulin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Timolol
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
EGD with metal duodenal stent
History of Present Illness:
Dr. ___ is a pleasant ___ gentleman with history of
metastatic cholangiocarcinoma who recently underwent removal of
a plastic stent with placement of a metal stent in the hepatic
duct at ___ on ___, was discharged on ___ and returns today
for vomiting and early satiety. He was initially seen by his
PCP in ___, ___ was performed there showing duodenal wall
thickening and he was transferred here for further evaluation.
Pt states that his sxs have been gradually worsening over the
last 3 wks, however he expected improvement with his recent
procedure and has found that his symptoms are worsening.
In the ED, initial vitals were 98.2 77 147/95 16 98%. Exam was
notable for soft abd, NT/ND, no peritoneal signs. Labs were
notable for elevated AST/ALT/AP. CT showed duodenal thickening
and distended stomach. GI was consulted and requested ___
campus admission for duodenal stenting in the AM. The patient
had no further episodes of N/V while in the ED.
On arrival on the floor, pt c/o mild abd pain and distension.
He denies nausea, last episode of vomiting was nearly 24 hrs
ago. He has not eaten since the morning of presentation and at
that time was only able to eat ___ package of ramen noodles. He
does have some anxiety and insomnia which he states did not
improve with 1 mg of ativan given in the ED.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. Last BM was 1 day ago. He states that he is passing
flatus.
Past Medical History:
PMH: Exercise induced asthma, hx. prostate cancer, glaucoma,
cholangiocarcinoma
PSH: ORIF R wrist (___), intraocular lens replacement, TURP,
ERCP (___)
Social History:
___
Family History:
No family history of cholangiocarcinoma. Father with MM,
brother with prostate CA.
Physical Exam:
VS - 97.8 181/73 67 18 100% RA
GENERAL - thin, well-appearing man in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - hyperactive BS, well healed surgical scars,
soft/mildly tender throughout without rebound or guarding,
non-distended, no masses or HSM
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
Admission labs:
___ 11:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:50PM GLUCOSE-103* UREA N-8 CREAT-0.7 SODIUM-136
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-25 ANION GAP-14
___ 08:50PM ALT(SGPT)-107* AST(SGOT)-64* ALK PHOS-412*
TOT BILI-0.7
___ 08:50PM LIPASE-55
___ 08:50PM ALBUMIN-3.7
___ 08:50PM WBC-6.7 RBC-4.16* HGB-12.4* HCT-35.9* MCV-86
MCH-29.8 MCHC-34.5 RDW-14.2
___ 08:50PM NEUTS-66.5 ___ MONOS-6.4 EOS-3.2
BASOS-0.6
___ 08:50PM PLT COUNT-184
CT abd:
-Biliary stent in appropriate position
-Distended stomach with marked wall thickening of the proximal
duodenum
-Moderate intra-hepatic biliary ductal dilatation slightly
increased since
most recent prior
-Significant fat stranding extending from the porta hepatis
inferior to the
liver with focal areas of nodularity. More extensive as compared
to ___.
Differential includes spread of cholangiocarcinoma vs
non-specific
inflammatory changes
-Small focus of air in the gallbladder fossa, possibly within a
collapsed
gallbladder
-New scalloping along the liver capsule - concerning for
metastatic disease
-Mild abdominal ascites
CXR ___: PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS:
New left lower lobe opacity is associated with volume loss,
manifested by
posterior displacement of the left major fissure. A left
pleural effusion has
increased in size, and is now moderate with a likely subpulmonic
component.
New poorly-defined somewhat nodular opacities have developed in
the right
upper lobe. Cardiomediastinal contours are stable in appearance
except for
slight inferior displacement of the left hilum. Small right
pleural effusion
has slightly increased in size and is associated with adjacent
opacity in the
right retrocardiac area.
IMPRESSION:
1. New left lower lobe opacity. Rapid development and
associated volume loss
favor atelectasis over infectious pneumonia.
2. New poorly defined opacities in right upper lobe, which
could represent
developing bronchopneumonia or an acute aspiration event.
3. Moderate left pleural effusion with apparent subpulmonic
component. Small
right pleural effusion.
___. ___
___ 07:00AM BLOOD WBC-6.7 RBC-3.90* Hgb-11.3* Hct-33.8*
MCV-87 MCH-28.9 MCHC-33.3 RDW-14.9 Plt ___
___ 07:00AM BLOOD Glucose-99 UreaN-4* Creat-0.5 Na-135
K-3.8 Cl-100 HCO3-27 AnGap-12
___ 07:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.7
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
2. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Montelukast Sodium 10 mg PO DAILY
5. Famotidine 20 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 6 Days
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
3. Benzonatate 100 mg PO TID:PRN Cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough
RX *codeine-guaifenesin [Guaiatussin AC] 100 mg-10 mg/5 mL 5 ml
by mouth twice a day Disp #*1 Bottle Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
7. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
8. Montelukast Sodium 10 mg PO DAILY
9. Metoclopramide 10 mg PO TID:PRN hiccups
stop immediately if diffuculty with speech or opening jaw
RX *metoclopramide HCl 10 mg 1 tablet(s) by mouth three times a
day Disp #*24 Tablet Refills:*0
10. Levofloxacin 750 mg PO Q24H Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Small bowel obstruction
2. Pneumonia, aspiration
3. Metastatic Cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with recent diagnosis of cholangiocarcinoma.
Patient is status post ERCP five days prior with placement of a metallic
common bile duct stent. Patient is now presenting with vomiting.
COMPARISON: CT abdomen and pelvis from ___ and CT abdomen and
pelvis from ___.
TECHNIQUE: Outside hospital images from ___ were
presented for second opinion review. Multidetector CT images of the abdomen
from the lung bases to the iliac crests were displayed with 5-mm slice
thickness. Intravenous contrast was administered. Coronal and sagittal
reformations were prepared.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Redemonstrate is focal bronchiectasis
with probable mucous plugging in the right middle lobe, unchanged from prior
(3:2). No pulmonary nodule or effusion is identified. The imaged cardiac
apex is within normal limits.
Redemonstrated is an irregular soft tissue density mass extending from the
hepatic hilum along the biliary tree, findings consistent with patient's known
history of cholangiocarcinoma. Additionally, there is marked fat stranding
and irregular soft tissue density extending inferiorly from the porta hepatis
to surround the ascending colon and proximal duodenum. As compared to CT
abdomen from ___, this soft density is more extensive and now
has a nodular appearance. Differential considerations include spread of
primary tumor or non-specific inflammatory changes. Additionally, there is
new scalloping along the liver capsule (3:11, 18, 20), which is concerning for
metastatic spread.
There is moderate intrahepatic biliary ductal dilatation, which has progressed
since the most recent prior examination from ___. A metallic
stent within the common bile duct appears in expected position. A punctate
foci of air is seen in the gallbladder fossa, likely within a decompressed
gallbladder (3:30). The hepatic veins and portal venous system are grossly
patent.
The stomach is markedly distended and filled with fluid. There is severe
diffuse wall thickening of the proximal duodenum (3:32) as it courses medial
to the porta hepatis in the above described region of irregular soft tissue
density. The lumen of the proximal duodenum appears compressed likely due to
extrinsic mass effect. More distal loops of small bowel are normal in caliber
and with signs of acute inflammation. There is a mild amount of free fluid
throughout the abdomen.
The spleen appears normal. The adrenal glands are symmetric without focal
nodule. There is symmetric enhancement and excretion of both kidneys without
suspicious focal lesion or hydronephrosis. Redemonstrated is atrophy of the
pancreatic tail and irregular upstream dilatation of the pancreatic duct,
unchanged from prior. The pancreatic duct is not visualized in the region of
the head and neck, similar to prior, though no discrete mass lesion is
identified at the site of transition. Scattered subcentimeter hypodense
lesions in the pancreatic parenchyma may represent dilated side branches of
the duct or small cystic lesions, similar to the prior. Known enlarged lymph
nodes within the portacaval and peripancreatic region are not well seen
secondary to significant stranding in this region. Incidental note is made of
a duplicated IVC.
BONES AND SOFT TISSUES: No bone destructive lesion or acute fracture is
identified.
IMPRESSION:
1. Dilated stomach with marked wall thickening of the proximal duodenum as it
passes near the porta hepatis at site of infiltrative tumor, consistent with
duodenal outlet obstruction with possible infiltration of the duodenum.
2. Progressive irregular soft tissue density extending from the hepatic hilum
inferiorly. Then nodular character of this density suggests progression of
primary tumor and less likely non-specific inflammatory changes
3. Scalloping along the liver capsule concerning for metastases.
4. Common bile duct stent in expected position, though progression of
intrahepatic biliary ductal dilatation.
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Right upper quadrant pain, question free air.
___.
FINDINGS: The lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. No evidence of free air is seen beneath the diaphragm.
IMPRESSION: No acute cardiopulmonary process. No evidence of free air
beneath the diaphragm.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS:
New left lower lobe opacity is associated with volume loss, manifested by
posterior displacement of the left major fissure. A left pleural effusion has
increased in size, and is now moderate with a likely subpulmonic component.
New poorly-defined somewhat nodular opacities have developed in the right
upper lobe. Cardiomediastinal contours are stable in appearance except for
slight inferior displacement of the left hilum. Small right pleural effusion
has slightly increased in size and is associated with adjacent opacity in the
right retrocardiac area.
IMPRESSION:
1. New left lower lobe opacity. Rapid development and associated volume loss
favor atelectasis over infectious pneumonia.
2. New poorly defined opacities in right upper lobe, which could represent
developing bronchopneumonia or an acute aspiration event.
3. Moderate left pleural effusion with apparent subpulmonic component. Small
right pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with VOMITING
temperature: 97.7
heartrate: 63.0
resprate: 18.0
o2sat: 97.0
sbp: 151.0
dbp: 78.0
level of pain: 2
level of acuity: 3.0 | Mr ___ is a pleasant ___ yo gentleman with hx of
cholangiocarcinoma, s/p biliary stenting on ___ now returning
with vomiting and evidence of duodenal wall thickening on CT,
concerning for partial SBO.
# PARTIAL SBO: likely due to duodenal thickening, likely from
spread of his cholangiocarcinoma. Patient underwent EGD with
duodenal stenting with good results. He was able to slowly
advance to a regular diet. He will avoid large food boluses,
ruffage, or fiber, which could get stuck in the stent. He was
seen by Nutrition to discuss appropriate food and nutritional
supplement intake.
# CHOLANGIOCARCINOMA: Patient is s/p ERCP on last admission.
Although LFTs were elevated above baseline on this admission,
they trended down without intervention. Patient will follow-up
with his oncologist as an outpatient or seek cancer care closer
to home in ___.
# COUGH/ELEVATED WBC/?PNA: Patient with cough, elevated WBC
and question of PNA on CXR. Patient likely aspirated during
procedure in light of duodenal blockage. Levofloxacin 750mg QD
was started for a total of 5 days.
# ASTHMA: Advair was continued. Singulair was held in an
effort to minimize medications patient needed to take orally.
# HICCUPS: Patient with severe hiccups. Reglan was helpful at
time. This medication can be continued as an outpatient. He
also found that deep breathing and relaxation helped this.
# GLAUCOMA: Latanoprost was continued. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
___ w/ hx HTN, DMII, ___ (EF>55%), ESRD on ___ HD since ___,
ex-smoker (quit 1970s), presumed myelodysplastic syndrome, p/w
dyspnea and mild somnolence today preceded by ___ weeks
nonproductive cough. HE was seen by ___ who found him to O2 82%
on RA (normally runs 96-100%). He was sent to ___ by ___ MD.
___ triggered for hypoxia at triage for O2 sat 88%RA (not on
home O2). Wife noted that ___ has had a dry cough for 1 week
but unknown if he has had fevers. He remains at baseline with 2
pillow orthopnea and wheelchair bound. ___ did have
scheduled HD yesterday and has not recently missed any sessions,
though dialysis schedule this week was MTF because of the
holidays. Review of systems negative for any fevers, chills,
chest pain, nausea, vomiting, diarrhea. Of note, ___ is
oliguric at baseline.
Further history obtained from daughter was that ___ started
getting URI symptoms on ___ with seemingly productive cough
on ___ though he was unable to produce sputum. He did have a
low grade temperature of 99.5 and was noted to be sluggish. His
daughter noted that ___ started having what appeared to be a
productive cough though he was never actually able to produce
sputum. ___ has not had any sick contacts. He did not get
the flu shot. ___ denies any myalgias.
He has had multiple hospitalizations over the last ___ years for
hyperkalemia in the setting of missed dialysis session
(___), anemia with guaic positive stools and
supratherapeutic INR (etiology not identified - ___,
pneumonia (___), and CHF (___) at which time BNP was
3600.
In the ED initial vitals were: 17:25- 0 99.1 66 157/38 22 88% ea
- Labs were significant for lactate 2.4, VBG 7.42/50, trop 0.09,
BNP 31074 (BNP 3600 in ___ at time of chf exacerbation),
leukocytosis 35.7, h/h 12.5/38.1, thrombocytosis 838 (Noted 550
on ___
- Bedside u/s showed no pericardial effusion but with b/l
pleural effusions
- ___ was given 1g vanc, 4.5g IV pip-tazo empirically for
possible HCAP
Vitals prior to transfer were: 20:24- 0 82 24 96% Nasal Cannula
On the floor, ___ denies any shortness of breath, chest
pain, or discomfort.
Past Medical History:
1. Hypertension.
2. Diabetes mellitus, type 2.
3. Diastolic dysfunction
4. Peripheral vascular disease with possible left carotid
stenosis, followed by Dr. ___ at ___
5. possible history of past TIA.
6. Macrocytic anemia/ presumed myelodysplastic syndrome (not
biopsy-proven)
7. History of squamous cell carcinoma.
8. History of gout, on allopurinol
9. chronic kidney disease stage V, started HD ___
Social History:
___
Family History:
No family history of cardiac disease or cancer that he knows of
Physical Exam:
ADMISSION:
Vitals - T97.7 159/59 HR74 RR30 96%6L NC 93.7kg (Dry weight:
unclear, 92.5kg ___
GENERAL: appears to be in mild distress (thoughe he denies),
speaking in 5 word sentences, audible expiratory coarse breath
sounds, persistent coughing during interview
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, unable to assess JVD
CARDIAC: irregularly irregular, bradycardic, S1/S2, ___ sys
murmur LUSB
LUNG: coarse breath sounds throughout, wheezing on expiration,
some use of accessory muscles
ABDOMEN: soft, rounded with accessory muscle use, +BS, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 2+ pitting edema extending up to knees, moving all
4 extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, sensation intact throughout
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
bilateral toes with some eschar though no evidence of active
infection
DISCHARGE:
98.4 116/41-139/49 ___ 95% RA
GEN: NAD
HEENT: conjunctiva pink, sclera anicteric
NECK: supple, no LAD, no SCM use, JVP difficult to appreciated
CV: ___, no m/r/g
LUNG: rhonchi diffusely, prolong expiratory wheezes, both
improved from admission
ABD: obese, soft, nt nd
EXT: trace pitting edema b/l
NEURO: grossly intact b/l
Pertinent Results:
ADMISSION:
___ 05:40PM BLOOD WBC-35.7*# RBC-3.42*# Hgb-12.5*#
Hct-38.1*# MCV-111* MCH-36.5* MCHC-32.8 RDW-20.5* Plt ___
___ 05:40PM BLOOD Neuts-74* Bands-4 Lymphs-12* Monos-9
Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-1*
___ 05:40PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Target-1+ Stipple-OCCASIONAL Tear
___
___ 05:40PM BLOOD Plt Smr-VERY HIGH Plt ___
___ 05:40PM BLOOD ___ PTT-30.2 ___
___ 05:40PM BLOOD Glucose-127* UreaN-36* Creat-5.8* Na-140
K-4.9 Cl-95* HCO3-27 AnGap-23*
___ 05:40PM BLOOD CK(CPK)-24*
___ 05:40PM BLOOD CK-MB-1 cTropnT-0.09* ___
___ 05:40PM BLOOD Calcium-9.6 Phos-4.5 Mg-2.2
___ 05:47PM BLOOD Lactate-2.4*
DISCHARGE:
___ 06:25AM BLOOD WBC-24.3* RBC-2.83* Hgb-10.4* Hct-31.1*
MCV-110* MCH-36.8* MCHC-33.4 RDW-20.3* Plt ___
___ 06:25AM BLOOD Plt Smr-VERY HIGH Plt ___
___ 06:25AM BLOOD Glucose-111* UreaN-56* Creat-7.5*# Na-136
K-5.0 Cl-93* HCO3-26 AnGap-22*
___ 06:25AM BLOOD Calcium-9.0 Phos-6.5* Mg-2.1
IMAGINE:
CXR IMPRESSION:
Persistent small to moderate size right pleural effusion with
right basilar opacity, likely compressive atelectasis. Minimal
streaky left basilar atelectasis. Mild pulmonary vascular
congestion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. Amlodipine 10 mg PO DAILY ONLY ON NONDIALYSIS DAYS
3. Aspirin 81 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Renagel 300 mg Other TID
8. Acetaminophen Dose is Unknown PO Q6H:PRN muscle aches
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN muscle aches
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Aspirin 81 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Amlodipine 10 mg PO DAILY ONLY ON NONDIALYSIS DAYS
8. Renagel 300 mg Other TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
viral URI
acute on chronic dCHF
ESRD on Dialysis
CHRONIC:
HTN
PVD
DMII
MDS
AFib
GOUT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with dyspnea
TECHNIQUE: Portable upright AP view of the chest
COMPARISON: ___
FINDINGS:
Heart size remains mildly enlarged. Mediastinal and hilar contours are
similar. Mild pulmonary vascular congestion is noted. A small right pleural
effusion persists with associated right basilar compressive atelectasis.
Streaky left opacity in the left lung base also likely reflects atelectasis.
No pneumothorax is identified. Moderate multilevel degenerative changes are
re- demonstrated in the thoracic spine.
IMPRESSION:
Persistent small to moderate size right pleural effusion with right basilar
opacity, likely compressive atelectasis. Minimal streaky left basilar
atelectasis. Mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: CHEST PA AND LATERAL
INDICATION: ___ hx dCHF (EF>55%), ESRD on MWF HD, ex-smoker (quit 1970s) p/w
dyspnea and mild somnolence today preceded by ___ weeks nonproductive cough
with concern for hcap and acute on chronic dCHF. Evaluate for acute
cardiopulmonary process, ?PNA.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___, and ___.
FINDINGS:
The heart remains mildly enlarged, without significant change in the
mediastinal and hilar contours. There is a persistent right pleural effusion,
largely unchanged, with likely right basilar atelectasis. There is also a
streaky left lung base opacity which may be atelectasis, also unchanged.
Moderate degenerative changes of thoracic spine are demonstrated.
IMPRESSION:
1. Largely unchanged chest radiograph since ___, with a similar
appearing right pleural effusion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with SEMICOMA/STUPOR
temperature: 99.1
heartrate: 66.0
resprate: 22.0
o2sat: 88.0
sbp: 157.0
dbp: 38.0
level of pain: 0
level of acuity: 1.0 | ___ w/ hx dCHF (EF>55%), ESRD on MWF HD since ___, ex-smoker
(quit ___) p/w dyspnea and mild somnolence today preceded by
___ weeks nonproductive cough with concern for hcap and acute on
chronic dCHF. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
morphine / Cefzil / Dilantin
Attending: ___.
Chief Complaint:
status epilepticus
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
Ms. ___ is a ___ woman with epilepsy who presents from clinic
with seizures.
PER ___ note:
"She has suffered from complex partial epilepsy since the age of
___ with secondary generalization. Seizure semiology begins
with aura of gastric rising sensation, followed by right facial
twitching, right arm flexion. She has semi-purposeful movements
and slightly impaired awareness. She calls these "small
seizures"
but notes that if she has generalization to a larger seizure,
which includes leg twitching and what she describes as a
stronger
gastric sensation, she notes that she typically has seizure
clusters. She did not endorse any gastric rising sensations to
me
leading up to the event. When she feels as if she will cluster,
she typically reaches for her rescue 1mg dissolvable clonazepam.
She goes to the ED every time she has a seizure over 5 minutes
or
if she has seizure clusters.
She has had to be admitted to the hospital frequently and has
had
multiple ED visits over the past month. In our system, she was
admitted in ___ and ___ (just discharged last week). The
patient herself notes thats she has had many hospitalizations
with at least two intubations secondary to medication
non-adherence.
She notes that while she was in school at ___, and even
now, she occasionally (several times a week) misses her
medications, particularly her morning doses, as she forgets to
take them or when she remembers she is sometimes too embarrassed
to take them in public.
Seizure frequency is at least once or twice a month. She has had
two hospitalizations in ___ (most recently at ___ last
week, earlier in ___ she was in ___). She was also
hospitalized at ___ (intubated) and intubated at ___ in ___ for management of status. On all occasions, she notes
triggers/exacerbations included medication non-adherence (at
baseline, missing at least ___ morning doses a week) in the
setting of: sleep deprivation (staying up late, ___ practice
division 1 waking up early, running in heat, and around her
menses potentially. Regarding a possible association of her
seizures with menses, she notes that she recently received a
hormone implant in her arm and that has made her period even
more irregular.
On two of her different hospitalizations, she was given Dilantin
and broke out into hives. She also reports a period of Dilantin
toxicity, where she was "walking into walls" at ___.
In her last hospitalization at ___ last week, she initially
presented to ___ and was transferred to our facility after
having a witnessed GTC with right gaze deviation. She was given
500mg IV keppra and 1mg IV Ativan and transferred to ___ ED
where she progressed into status epilepticus in the setting of
missed lamotrigine and keppra doses. She was loaded with
lacosamide, which was discontinued on discharge given her return
to baseline and normalized cvEEG. Her AED regimen on discharge
was unchanged and included lamictal 150/175 and keppra 1g BID as
well as clonazepam 0.25mg BID (which the patient says she has
not
been taking for 3 weeks with exception of hospital admission
last
week where she was given it).
Since discharge from hospital, she says she has been adherent
with her medications. She has been sleeping well but does have
some stress related to medical leave of absence from ___.
She took this in ___ and moved back in with her mother and
her mother's boyfriend, which she says is "not ideal" wishing
that she can return to college living ("but without the
college.")
No recent sicknesses, colds, dysuria."
She now presenst to ___ ED for breakthough seizure. Per OMR
note:
"During her clinic visit, she suffered a complex
partial seizure with secondary generalization. The event began
during physical exam and after history was obtained. As I asked
her to extend her extremities for evaluation of pronator drift,
she developed a subtle right hand tremor. She continued to talk
to me throughout the tremor, noting that sometimes her hand
shakes a little from "nerves." Within seconds, she developed a
right facial twitch with right eye and then left eye twitching.
She was still responding to me and was regarding me with
semi-purposeful movements during this episode but I called for
assistance with bracing the patient concerned that she will soon
generalize. She then became unresponsive to me but with warm
extremities, a strong and regular pulse, and normal
respirations.
I turned her to lie on her right side on the table. Her eyes
then
deviated to the right, her teeth chattered, she was foaming at
the mouth but did not turn blue. Her right arm flexed, curling
towards her core, her left arm stiffened, and both her lower
extremities stiffened for <3 seconds followed by low-grade
convlusions. This generalized episode (right arm flexion,
bilateral leg twitching, right head deviation, eye deviation to
the right) lasted approximately ___ seconds and then resolved
although without return to baseline status, with relaxed
extremities and midline gaze although with ongoing ocular
flutter. She remained in the more-relaxed phase for
approximately
1 minute followed by successive ~40-second generalized seizures.
Time span was roughly 10 minutes prior to EMS arrival. I gave
her
2x 1mg disintegrating clonazepam (which I took out of her bag as
she told me she carries an emergency supply) while awaiting for
EMS.
On EMS team arrival, vitals were stable, she was saturating 98%
on RA. IV was placed but Ativan was not available as part of
code
cart. She was taken urgently downstairs by EMS team and a
call-in
was placed to the ED. She remained unresponsive to voice and
verbal stimuli throughout her event, starting at approximately
___ (EMS departure time)."
On arrival to ___ ED patient note to be seizing with head and
eyes devaited to the right as wella s RUE stiffening.
She was given Ativan a ___ of 6 mg and loaded with keppra 1g
and lacosamide 200mg x1 with resolution of seizure. ___,
___
adter she bgean seizing again and was intubated.
Prior AEDs tried:
- lacosamide (was discontinued on discharge from last
hospitalization)
Past Medical History:
Complex partial seizures with secondary generalization
Social History:
___
Family History:
Per mother, negative for seizures, but father's family history
unknown.
Physical Exam:
EXAM ON ADMISSION:
=================
Vitals: P67, BP117/86, RR20, 100% RA
General: seizing with RUE stiffening and head to the right and
eyes deviated to right
HEENT: Unable to assess
CV: RRR
Pulm: CTAB
Abd: s/nt/nd
Ext: no c/c/e
Neuro:
-MS: currently seizing unable to assess MS
-CN:PERRL, right gaze deviation, face symmetric. Corneal
reflexes/lash stimulation present bilaterally.
-Motor: moves all 4's antigravity but R<L
DTRs: 2+ throughout, toes mute
Discharge Exam
================
24 HR Data (last updated ___ @ 1525)
Temp: 98.6 (Tm 98.6), BP: 104/67 (93-106/58-68), HR: 56
(49-77), RR: 18 (___), O2 sat: 99% (95-99), O2 delivery: Ra
- General: Awake, cooperative, EEG leads in place
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: warm and well perfused
- Abdomen: non distended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Speech is fluent, follows
both axial and appendicular commands
-Cranial Nerves: 3 to 2mm and brisk. EOMI without nystagmus,
face
symmetric, tongue midline
-Motor: Normal bulk, tone throughout. High frequency low
amplitude tremor noted with arms outstretched. No pronator
drift, spontaneous and
antigravity throughout, able to kick my hands bilaterally and
hold antigravity for >5 mins.
-DTRs: deferred
-___: No deficits to light touch
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally.
-Gait: deferred, but patient up walking to bathroom without
issues
Pertinent Results:
Admission Labs
===============
___ 03:36AM BLOOD WBC-9.9 RBC-3.94 Hgb-10.2* Hct-30.9*
MCV-78* MCH-25.9* MCHC-33.0 RDW-13.0 RDWSD-37.1 Plt ___
___ 03:36AM BLOOD ___ PTT-25.7 ___
___ 03:36AM BLOOD Glucose-115* UreaN-4* Creat-0.7 Na-141
K-3.9 Cl-106 HCO3-23 AnGap-12
___ 03:36AM BLOOD CK(CPK)-1087*
___ 06:22PM BLOOD Lipase-66*
___ 06:22PM BLOOD cTropnT-<0.01
___ 03:36AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.8*
___ 06:28PM BLOOD Lactate-1.5 K-3.8
___ 06:32PM BLOOD LEVETIRACETAM (KEPPRA)-PND
___ 06:32PM BLOOD LAMOTRIGINE-PND
CSF
===
___ 05:32PM CEREBROSPINAL FLUID (CSF) TNC-0 RBC-0 Polys-0
___ ___ 05:32PM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-66
Discharge Labs
==============
___ 05:05AM BLOOD WBC-5.5 RBC-4.53 Hgb-11.4 Hct-35.6
MCV-79* MCH-25.2* MCHC-32.0 RDW-13.2 RDWSD-37.6 Plt ___
___ 05:05AM BLOOD Glucose-87 UreaN-9 Creat-0.9 Na-140 K-4.1
Cl-102 HCO3-26 AnGap-12
Imaging
========
MRI ___
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are
within expected limits in caliber and configuration.
Bilateral hippocampal formations and mammillary bodies are
preserved in signal and configuration. There is no
disproportionate medial temporal atrophy. There is no focal
lobar encephalomalacia. There are no focal cortical dysplasias
or gray matter heterotopia noted.
IMPRESSION:
1. Unremarkable contrast enhanced MRI brain.
2. No evidence of focal cortical dysplasia, focal lobar
encephalomalacia, gray matter heterotopia or mesial temporal
sclerosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FLUoxetine 40 mg PO DAILY
2. LamoTRIgine 150 mg PO QAM
3. LamoTRIgine 175 mg PO QPM
4. LevETIRAcetam 1000 mg PO Q12H
5. ClonazePAM 1 mg PO QID:PRN anti seizure
Discharge Medications:
1. LamoTRIgine 300 mg PO BID
Follow separate instructions on how to increase slowly to this
dose
RX *lamotrigine 150 mg 2 tablet(s) by mouth every 12 hours Disp
#*120 Tablet Refills:*5
RX *lamotrigine 25 mg ___ tablet(s) by mouth every 12 hours Disp
#*180 Tablet Refills:*0
2. ClonazePAM 1 mg PO QID:PRN anti seizure
3. FLUoxetine 40 mg PO DAILY
4. LevETIRAcetam 1000 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Breakthrough seizures
complex partial epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ___ CLINIC PROTOCOL W/O CONTRAST T7721 MR HEAD
INDICATION: ___ year old woman with hx of seizure d/o of unclear etiology//
Evaluate for intracranial pathology
TECHNIQUE: Sagittal 3D FLAIR, axial GRE, coronal FSTIR, axial DTI, images
were obtained. Additional sagittal and axial reformatted images of the MPRAGE
images were then produced. All images were reviewed in the production of this
report. The examination was performed using a 3.0T MRI scanner.
COMPARISON: None available.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are within expected limits in
caliber and configuration.
Bilateral hippocampal formations and mammillary bodies are preserved in signal
and configuration. There is no disproportionate medial temporal atrophy. There
is no focal lobar encephalomalacia. There are no focal cortical dysplasias or
gray matter heterotopia noted.
IMPRESSION:
1. Unremarkable contrast enhanced MRI brain.
2. No evidence of focal cortical dysplasia, focal lobar encephalomalacia, gray
matter heterotopia or mesial temporal sclerosis.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | ___ year old female with focal seizure with decreased awareness
and secondary generalization admitted with breakthrough
seizures.
#Seizures: Seizures since the age of ___, unknown etiology.
She presented with breakthrough seizures, thought to be from
missing doses as well as irregular schedule and sleep
deprivation. Also possibly some catamenial component as
increased seizures with menstruation. She was intubated for
airway protection in the ED. While in ICU she was quickly
extubated. She had an event after extubation consisting of right
arm triple flexion, rightward gaze preference but no EEG
correlate. For workup of her epilepsy that has been difficult to
control recently she had MRI that did not show any focal
cortical dysplasia, focal lobar encephalomalacia, grey matter
heterotopia, or mesial temporal sclerosis. LP was done as well
without evidence of increased protein or infection.
Encephalopathy panel was sent and pending at time of discharge.
She was continued on lamictal 150/175mg, Keppra 1000mg BID.
Level of lamictal was checked and pending at time of discharge.
Overall feel that breakthrough seizures are iso non compliance
as she has difficulty taking her morning medications due to her
friends seeing her and not wanting them to know she takes
medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
codeine
Attending: ___
Chief Complaint:
Speech difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ yo man with a PMHx of a L MCA stroke in ___
with
resulting fluent-aphasia, pancreatic cancer with known liver
mets, afib on Eliquis, HTN and HLD who presents to the ED with
worsening slurred speech and word finding difficulties with MRI
revealing subacute to late acute bilateral cerebellar
hemispheres
and left temporal lobe embolic infarcts.
On ___, pt resumed chemotherapy with FOLFIRINOX. Pt had been
off while recovering from his previous stroke. After the
therapy,
pt initially felt well. On ___, he felt generalized weakness
and almost passed out. He also felt "burning everywhere" and a
sore mouth and throat.
Over the weekend, pt developed progressive confusion. For
instance, he was trying to "test his blood with a TV remote" per
sister. On ___, sister found pt to be "not making sense" and
felt pt was having a worsening of his baseline aphasia. She then
emailed the oncology nurse to make an urgent appt.
During the appt on day of presentation, ___, a STAT MRI was
ordered. This revealed subacute to late acute bilateral
cerebellar hemispheres and left temporal lobe embolic infarcts
prompting referral to ED.
At the time of my assessment, sister was present and reported
that pt's symptoms were now gradually improving. Pt reported
feeling weak but felt that his speech was improving.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies loss of vision, blurred
vision, diplopia, vertigo, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
- pancreatic cancer with known liver mets
- Afib
- HTN
- HLD
- prior MI s/p catheterization
- asthma, COPD
- DM
- depression
Social History:
___
Family History:
- unable to be obtained
Physical Exam:
HR: 100s prior to discharge
General: NAD, resting in bed comfortably
HEENT: NCAT, no oropharyngeal lesions
___: Irregularly irregular
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Speech with improved fluency, still with added words but
overall coherent speech. Improved naming of low frequency
objects ___ on stroke card, w/ phonemic errors w/ "hammock" and
"cactus". Repetition with phonemic and semantic errors. Mild
dysarthria. No evidence of hemineglect.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk, power and tone. No drift. No tremor or
asterixis.
- Sensory - No deficits to light touch bilaterally.
Plantar response extensor on the L, mute on the R.
- Coordination - Mild overshoot w/ L > R on FNF in upper
extremities. Good speed and intact cadence with rapid
alternating movements.
- Gait - Deferred.
Pertinent Results:
___ 04:08PM BLOOD WBC-3.0* RBC-3.01* Hgb-9.0* Hct-28.4*
MCV-94 MCH-29.9 MCHC-31.7* RDW-14.8 RDWSD-50.6* Plt Ct-57*
___ 04:45AM BLOOD WBC-3.7* RBC-3.12* Hgb-9.2* Hct-29.8*
MCV-96 MCH-29.5 MCHC-30.9* RDW-15.0 RDWSD-52.3* Plt Ct-27*
___ 10:20AM BLOOD WBC-5.4 RBC-3.40* Hgb-10.3* Hct-32.6*
MCV-96 MCH-30.3 MCHC-31.6* RDW-14.9 RDWSD-51.8* Plt Ct-48*#
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD Glucose-162* UreaN-11 Creat-0.9 Na-139
K-3.6 Cl-103 HCO3-26 AnGap-14
___ 04:30PM BLOOD ALT-22 AST-22 AlkPhos-156* TotBili-0.5
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with cva, pancreatic cancer, worsens speech and
fatigue // Eval status of cva
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MRI head with without contrast of ___, CT head without
contrast of ___.
FINDINGS:
The examination particularly the postcontrast sequences are motion degraded.
Within these confines:
There are 3 new foci of slow diffusion of the bilateral cerebellar
hemispheres, 2 in the left (series 502, image 2 and 3) and 1 in the right
(series 502, image 1). An additional punctate focus of slow diffusion of
inferior temporal lobe (series 502, image 7) appear separate from the prior
temporal infarct described in ___. These lesions demonstrate
associated FLAIR hyperintense signal, compatible with late acute to subacute
infarct. There is no clear associated enhancement, however postcontrast
sequences are severely motion limited.
Additional scattered foci of subtle cortical diffusion-weighted hyperintense
signal of the right frontal lobe (series 502, image 24), right postcentral
gyrus (series 502, image 223) and left medial frontal lobe along the
precentral gyrus (series 502, image 22) are noted without clear ADC correlate
and with equivocal associated FLAIR hyperintense signal are also suspicious
with additional foci of subacute infarct.
In the region of previous acute infarct, there is now developing
encephalomalacia with mildly enhancing gyriform cortical diffusion-weighted
hyperintense signal of the left temporal lobe and pseudo normalized ADC
correlate, compatible with subacute infarct. This region demonstrates T1
intrinsic hyperintense signal compatible with cortical laminar necrosis.
There is also superimposed gradient echo susceptibility blooming artifact
within the region of prior infarct, corresponding to known hemorrhagic
transformation demonstrated on CT examination of ___.
The major intracranial flow voids are preserved. The dural venous sinuses are
patent. The paranasal sinuses are clear. The patient is status post right
lens replacement, otherwise orbits are unremarkable. The mastoid air cells
demonstrate trace fluid signal at the tips.
IMPRESSION:
1. Multiple new foci of slow diffusion involving the bilateral cerebellar
hemispheres and left temporal lobe, demonstrating associated FLAIR
hyperintense signal without definitive enhancement, compatible with a
combination of late acute to subacute infarcts of varying chronicity.
2. Additional scattered foci of diffusion-weighted hyperintense signal without
clear ADC hypointensity and equivocal FLAIR hyperintense signal of the
bilateral frontal and right parietal lobes, concerning for subacute infarcts.
3. The above combination of findings would suggest a central/ embolic
etiology.
4. Subacute left temporal lobe infarct, now demonstrating encephalomalacia and
mildly enhancing gyriform diffusion-weighted cortical hyperintensity with
pseudo normalization on ADC and associated pseudo laminar necrosis. There is
gradient echo susceptibility blooming artifact within the subacute infarct
compatible with hemorrhagic transformation, noted on prior CT examination.
5. Potentially, the gyriform diffusion-weighted hyperintense signal of the
left temporal lobe could be seen in setting of seizure activity, however there
is no cortical thickening to suggest edema.
6. Postcontrast examination is severely motion degraded. No clear enhancing
mass lesions are identified.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephoneon ___ at 3:45 ___, at the time of
discovery of the findings.
Radiology Report
EXAMINATION: Chest radiographs.
INDICATION: ___ with increase confusion // eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs dated ___, CT chest dated ___.
FINDINGS:
Left central venous line terminates at the cavoatrial junction. Multiple
bilateral pulmonary nodules are better characterized on recent CT chest
examination. Bibasilar atelectasis is noted without lobar consolidation,
pleural effusion, pneumothorax, or pulmonary edema. The cardiomediastinal
silhouette is unchanged.
IMPRESSION:
Bibasilar atelectasis without lobar consolidation. Numerous pulmonary nodules
are better visualized on prior CT chest examination.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ male with with acute infarct on MRI. Evaluate for
aneurysm.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque350 intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
5) Spiral Acquisition 4.9 s, 38.5 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,234.2 mGy-cm.
Total DLP (Head) = 2,161 mGy-cm.
COMPARISON: CT from ___ and MRI from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Evolving cerebellar and left temporal lobe infarcts are seen with developing
encephalomalacia. There is a focus of encephalomalacia in the right frontal
lobe, likely from prior lacunar infarction.
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. Right cataract extraction changes are seen. There is minimal mucosal
thickening in the ethmoid sinuses. Cerumen is seen in the bilateral external
auditory canals.
CTA HEAD:
There is minimal atherosclerotic calcification of the cavernous carotid
arteries. Otherwise, the vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
There is minimal atherosclerotic calcification at the origin of the great
vessels and the bilateral carotid bulbs. Medialization of the internal
carotid arteries is seen. Otherwise, the carotid and vertebral arteries and
their major branches appear normal with no evidence of stenosis or occlusion.
There is no evidence of internal carotid stenosis by NASCET criteria.
OTHER:
Multiple enlarging nodules are seen in the bilateral lung apices, better
visualized on the dedicated CT chest from ___. Multiple small
mediastinal lymph nodes are seen. There is a partially visualized left
central venous catheter. The visualized portion of the thyroid gland is
within normal limits. There is no lymphadenopathy by CT size criteria.
Degenerative changes are noted throughout the cervical spine.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage. Evolving cerebellar and
left temporal lobe infarctions.
2. No evidence of aneurysm greater than 3 mm, dissection or vascular
malformation, or significant luminal narrowing.
3. Multiple enlarging lung nodules seen on CT chest from ___ which
likely represents progressive metastatic disease.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status, Facial droop
Diagnosed with Cerebral infarction, unspecified
temperature: 98.3
heartrate: 116.0
resprate: 16.0
o2sat: 100.0
sbp: 94.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | # Neuro: Patient presented with worsening dysarthria and word
finding difficult with MRI revealing late acute b/l cerebellar
hemisphere and left temporal lobe infarcts, suggestive of
cardioembolic etiology, also complicated by his underlying
metastatic malignancy which may place him in a hypercoagulable
state. Patient showed improvement in aphasia over course of
admission, with improvement in naming objects and fewer phonemic
and paraphasic errors. The patient was transitioned from
apixaban to enoxaparin for therapeutic anticoagulation and
medication was delivered to patient in the hospital. Blood
pressures were initially allowed to auto regulate and then
restarted on home antihypertensives upon discharge.
-Risk factor labs:
-HbA1c: 7.2 LDL: 149 TSH: 3.2 (CEA 218)
-CTA H/N: unremarkable
-MRI: Multiple new foci of slow diffusion involving the
bilateral cerebellar hemispheres and left temporal lobe,
demonstrating associated FLAIR hyperintense signal without
definitive enhancement, compatible with a combination of late
acute to subacute infarcts of varying chronicity. Additional
scattered foci of diffusion-weighted hyperintense signal without
clear ADC hypointensity and equivocal FLAIR hyperintense signal
of the bilateral frontal and right parietal lobes, concerning
for subacute infarcts. Subacute left temporal lobe infarct, now
demonstrating encephalomalacia and mildly enhancing gyriform
diffusion-weighted cortical hyper intensity with pseudo
normalization on ADC and associated pseudo laminar necrosis.
There is gradient echo susceptibility blooming artifact within
the subacute infarct compatible with hemorrhagic transformation,
noted on prior CT examination.
-Echo: Apical hypokinesis, worse from ___. No discrete
thrombus. Mild symmetric left ventricular hypertrophy. Increased
left ventricular filling pressure. Mild mitral and tricuspid
regurgitation
# CV: Admitted in atrial fibrillation with RVR, improved after
multiple IV doses of metoprolol and PO+IV Diltiazem, for which
increased home metoprolol from 250mg daily to 300mg total daily
dose.
# HEME: Pancytopenia, especially thrombocytopenia during
admission, likely secondary to recent chemotherapy
administration on ___. Platelets downtrended to 27 on
admission, without evidence of bleeding. After discussing case
with Oncologist Dr. ___ 1u platelets with
improvement in platelets to 57 upon discharge.
# ENDO: DM, continued on insulin with SSI as needed.
# ID: No evidence of infection on UA/UCx, CXR.
# Global:
- FEN: Maintained initially on cardiac heart healthy diet,
transitioned to regular per patient preference. Releted
electrolytes as needed
- DVT PPx: Therapeutic Lovenox, pneumoboots
- Bowel regimen
- Precautions: fall and aspiration
- Dispo: Floor bed with telemetry, ___ recommended outpatient ___,
paperwork filed for home ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / levofloxacin / vancomycin
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
___ Gastric Emptying Study
Markedly abnormal gastric emptying with only trace activity
leaving
the stomach for the small bowel after 4 hours.
___ PERC G/G-J TUBE PLMT
Successful placement of a 16 ___ MIC gastrojejunostomy tube
with its tip in the proximal jejunum. The gastric port should
not be used for 24 hours.
History of Present Illness:
In brief, this is a ___ female with PMHx significant for
IDDM c/b neuropathy, severe gastroparesis with frequent flares,
macular degeneration with legal blindness, and obesity, who is
presenting with nausea, vomiting, and abdominal pain. She was
admitted two weeks ago for a gastroparesis flare and had a
temporary NJ tube placed for a tube feeding trial with a plan to
have a follow up emptying study. Her feeding cycle was 16hr
continuous/8hr off. 4 days prior to admission and about 9hrs
into her feed, she felt her stomach becoming uncomfortably full,
which triggered her to become nauseated and vomit (NB, bilious)
and displaced her NJ tube. Following this episode, she reports
severe (___) LLQ abdominal pain. She denies fevers, chills,
chest pain, shortness of breath, dysuria, headache.
Past Medical History:
Diabetes x ___ years; last HgB A1C 8
Retinopathy (legally blind)
Glaucoma
Macular degeneration
Neuropathy in hands & feet
Severe gastroparesis x ___ years (had gastric emptying study)
Depression
Anxiety
h/o frequent UTIs
Hypertension
Social History:
___
Family History:
Notable for depression and DM in several family members.
Physical Exam:
ADMISSION PHYSICAL EXAM
===============================
VS 98.5 155 / 89 91 16 98 RA
GENERAL: Pleasant, obese female, NAD, quite tearful.
HEENT: normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: soft, TTP in LLQ, non-distended, no rebound or
guarding.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash on limited exam
NEUROLOGIC: A&Ox3, no focal deficits
DISCHARGE PHYSICAL EXAM
===============================
VS 97.7 | 142/64 | 88 | 18 | 96% RA
GENERAL: Pleasant, obese female, NAD.
HEENT: no conjunctival pallor or scleral icterus, PERRLA, EOMI,
OP clear.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: soft, mildly tender around GJ site, dressing c/d/I, no
discharge or erythema.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash on limited exam
NEUROLOGIC: A&Ox3, no focal deficits
Pertinent Results:
ADMISSION LABS
====================
___ 07:25PM BLOOD WBC-9.4 RBC-4.20 Hgb-12.1 Hct-36.7 MCV-87
MCH-28.8 MCHC-33.0 RDW-14.0 RDWSD-44.4 Plt ___
___ 07:25PM BLOOD Neuts-72.5* Lymphs-18.7* Monos-7.9
Eos-0.2* Baso-0.3 Im ___ AbsNeut-6.83* AbsLymp-1.76
AbsMono-0.74 AbsEos-0.02* AbsBaso-0.03
___ 07:25PM BLOOD Glucose-256* UreaN-20 Creat-0.9 Na-137
K-4.1 Cl-96 HCO3-29 AnGap-16
___ 07:25PM BLOOD ALT-10 AST-9 AlkPhos-71 TotBili-0.3
___ 07:15AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
___ 07:33PM BLOOD Lactate-1.4
STUDIES
====================
___ Gastric Emptying Study
IMPRESSION: Markedly abnormal gastric emptying with only trace
activity leaving the stomach for the small bowel after 4 hours.
___ GJ tube placement
1. Successful placement of a 16 ___ MIC gastrojejunostomy
tube with its tip in the proximal jejunum.
DISCHARGE LABS
====================
___ 08:00AM BLOOD WBC-7.7 RBC-4.14 Hgb-11.9 Hct-36.3 MCV-88
MCH-28.7 MCHC-32.8 RDW-13.6 RDWSD-43.4 Plt ___
___ 08:35AM BLOOD Glucose-231* UreaN-14 Creat-0.6 Na-138
K-4.0 Cl-97 HCO3-31 AnGap-14
___ 01:23PM BLOOD ALT-12 AST-16 LD(LDH)-145 AlkPhos-66
TotBili-0.5 DirBili-0.1 IndBili-0.4
___ 08:35AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Bisacodyl 10 mg PR QHS:PRN c
3. Docusate Sodium 100 mg PO BID
4. DULoxetine 60 mg PO DAILY
5. Lisinopril 20 mg PO DAILY
6. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
7. Omeprazole 20 mg PO BID
8. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
9. Dronabinol 2.5 mg PO BID
10. Simethicone 40-80 mg PO QID:PRN gassy feeling
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Glargine 60 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
Discharge Medications:
1. Glucerna 1.5 Cal (nut.tx.gluc.intol,lac-free,soy) 65 ml/hr
oral DAILY
65cc/hr for 16 hours per day
RX *nut.tx.gluc.intol,lac-free,soy [Glucerna 1.5 Cal] 65 cc/hr
by mouth daily Disp #*1000 Milliliter Refills:*0
2. amLODIPine 10 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN c
4. Docusate Sodium 100 mg PO BID
5. Dronabinol 2.5 mg PO BID
6. DULoxetine 60 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. LORazepam 1 mg PO Q8H:PRN anxiety, nausea
9. Omeprazole 20 mg PO BID
10. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN pain
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Simethicone 40-80 mg PO QID:PRN gassy feeling
13. Glargine 50 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
50 Units at bedtime Disp #*1 Syringe Refills:*0
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 12 units
at mealtimes Disp #*1 Syringe Refills:*0
14. ___ 12 Units Q24H
RX *insulin NPH and regular human [Humulin ___ KwikPen] 100
unit/mL (70-30) AS DIR 12 Units at start of tube feed every
night Disp #*3 Syringe Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
Gastroparesis flare, with nausea/vomiting/abdominal pain
SECONDARY DIAGNOSES
======================
IDDM with Retinopathy, Neuropathy, Gastropathy
Biliary ductal dilation
Depression
Chronic pain
Primary Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with IDDM and severe gastroparesis // please
place GJ tube for severe gastroparesis
COMPARISON: Nasointestinal tube placement ___. CT abdomen ___.
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
personally supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
250 mcg of fentanyl and 4.5 mg of midazolam throughout the total intra-service
time of 1 hr 30 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
CONTRAST: 75 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 51.7 min, 766 mGy
PROCEDURE: 1. Placement of a 16 ___ MIC gastrojejunostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol.
A Kumpe catheter was inserted using a stiff glidewire as an NG-tube in order
to insufflate the stomach. The abdomen was then prepped and draped in the
usual sterile fashion.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. A lateral spot view confirmed that no colon
was interposed between the stomach in the anterior abdominal wall. Using a
marker, the skin was marked using palpation to feel the costal margins and the
liver edge was marked using ultrasound.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. The needle
trajectory was directed towards the pylorus. A ___ wire was introduced and
coiled within the stomach. A small skin incision was made along the needle and
the needle was removed.
An 8 ___ sheath was placed after dilatation with 6 and 8 ___ serial
dilators. A combination of multiple catheters and wires were used to attempt
access into the small bowel, including a Kumpe, C2, ___ 1, angled glidewire,
straight glidewire, and ___ wire. This was very difficult given severe
gastroparesis with no contrast seen in the small bowel at any point prior to
small bowel access. Eventually, access was obtained into the small bowel
using a combination of the Cobra catheter and the ___ wire. The ___
wire was exchanged for ___ wire, over which the sheath was advanced into
the small bowel. The Cobra catheter was then exchanged for the ___ 1 catheter
and the ___ wire was advanced into the distal small bowel utilizing the
curved leading edge of the ___ 1 catheter. The catheter and sheath were then
removed over the wire. Dilation of the percutaneous tract was attempted using
serial dilators, but this was unsuccessful. The dilators were removed and a 7
mm balloon was advanced into the percutaneous tract and gently inflated. The
20 ___ peel-away sheath was then able to be advanced into the stomach. The
inner dilators were withdrawn over the wire.
Next, a 16 ___ MIC gastrojejunostomy catheter was advanced over the wire
into position. The sheath was then peeled away. The wire and sheath were
removed. The catheter was locked by instilling 7 ml of dilute contrast into
the balloon in the stomach after confirming the position of the catheter with
a contrast injection. The catheter was then flushed, capped and secured to the
skin with 0-silk sutures and the retention disc. Sterile dressings were
applied. The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip
in the proximal jejunum.
IMPRESSION:
Successful placement of a 16 ___ MIC gastrojejunostomy tube with its tip in
the proximal jejunum. The gastric port should not be used for 24 hours.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Type 1 diabetes w diabetic autonomic (poly)neuropathy, Long term (current) use of insulin, Gastroparesis
temperature: 98.3
heartrate: 108.0
resprate: 22.0
o2sat: 100.0
sbp: 130.0
dbp: 102.0
level of pain: 10
level of acuity: 2.0 | Summary
======================
___ female with PMHx significant for IDDM c/b
neuropathy, severe gastroparesis with frequent flares, macular
degeneration with legal blindness, and obesity, who is
presenting with nausea, vomiting, and abdominal pain, consistent
with gastroparesis. She underwent GJ tube placement and was
restarted on tube feeds.
ACTIVE ISSUES
=======================
# Nausea/vomiting/abdominal pain with gastroparesis: Patient
presented with two days of symptoms consistent with prior
gastroparesis flares. Patient was recently discharged with NJ
trial (to see whether permanent g tube would be beneficial).
Symptoms were improved with NJ, though temporary tube was
dislodged and prompted nausea/vomiting/abdominal pain, for which
pt was admitted this time. During this hospitalization, she
underwent gastric emptying study which was grossly abnormal and
then GJ tube placement on ___. Nausea, vomiting and abdominal
pain largely resolved on post-op day 2, tolerating tube feeds
and oral pain medication. She was discharged on pre-admission
pain regimen. Nutrition and ___ Diabetes were consulted, and
recommendations regarding tube feed regimen and diabetes
management were made (discussed below). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Wall Infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with history of depression with prior suicide
attempt c/b exploratory laparotomy, anxiety, and dyslipidemia
who presents with abdominal wall erythema and pain.
Of note, patient was seen in ___ surgery clinic ___
given hx of RUQ abdominal pain and cholelithiasis. Biliary
colic was considered most likely, patient was offered elective
laparoscopic cholecystectomy with Dr. ___ ___.
This past ___, patient first noticed a small, red bump just
below his umbilicus (slightly tender). He denies any trauma or
insect/tick bite in the area (no known exposures or recent
travel, no sick contacts). He aggravated the lesion somewhat
and it grew somewhat in size. Throughout this time, patient was
applying the standard pre-operative cleansing solution he had
been told to use prior to elective CCY in addition to an OTC
antimicrobial cream he had at home. Over the weekend, the
lesion did not change markedly in appearance, ~1cm in diameter,
erythematous and locally tender. On ___, patient was able to
express a modicum of purulent drainage. Starting ~12PM on
___ patient describes rapid progression of erythema,
exquisite pain (involving the mons pubis and L groin), and
swelling across his abdomen (now extending ~20cm in total around
the initial lesion). Patient denies any fever/chills. No
sensory loss in the area. Given the acute change in his
symptoms, patient decided to present to the ___ ED for further
evaluation and treatment.
In the ED, initial VS were: 97.1 95 138/92 17 100% RA
Exam notable for:
Benign cardiopulmonary exam
Well-appearing male
20 cm area of edema and erythema with a head of eschar,
nondraining. The area is markedly tender to palpation. There is
severe tenderness and pain extending beyond the erythema, down
towards the groin ending just at the pubic symphysis. No
crepitus.
Labs showed:
CBC 9.3>13.6/40.5<224 (76.2% PMNs)
BMP ___
ALT 15
AST 23
ALP 81
Tbili .4
Albumin 4.6
CRP 6.9
CK 190
Lactate .8
Imaging showed:
CT A/P with contrast ___
IMPRESSION:
1. Fat stranding in the anterior abdominal wall inferior to the
umbilicus consistent with reported history of cellulitis. No
abscess or subcutaneous gas is identified.
2. No acute process within the abdomen or pelvis.
3. Cholelithiasis without cholecystitis.
4. Dilated common bile duct to 0.8 cm without visualized
calcified stone or mass identified. Non urgent MRCP can provide
further evaluation for underlying etiology if desired
clinically.
Consults: ACS (no acute surgical intervention, recommend broad
spectrum abx, CCY likely postponed)
Patient received:
___ 20:22 IV Clindamycin
___ 20:42 IV Piperacillin-Tazobactam
___ 21:22 IV Piperacillin-Tazobactam 4.5 g
___ 22:40 IV Vancomycin (1000 mg ordered)
Transfer VS were: 98.7 82 113/76 16 98% RA
On arrival to the floor, patient recounts the history as above.
He continues to deny any fevers/chills. Severe pain only with
palpation of his abdominal skin lesion. No sensory loss. No
further drainage. Patient says that his symptoms have improved
greatly after the administration of antibiotics.
10-point ROS is otherwise NEGATIVE.
Past Medical History:
Depression c/b SI with past suicide attempts
Anxiety
H pylori infection s/p prior treatment with evidence of cure
Dyslipidemia
Cholelithiasis
Hypertriglyceridemia
Exploratory laparotomy iso ASA overdose ___ ago)
Social History:
___
Family History:
Father with prostate Cancer (___)
Mother with atypical polyp/colon cancer (43), breast cancer (65)
MGF deceased iso MI ___
Physical Exam:
ADMISSION PHYSICAL
==================
VS: 99.1 116/80 77 18 96 RA
GENERAL: NAD, comfortable appearin
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: No JVP elevation.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles.
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Skin exam as below.
EXTREMITIES: No cyanosis, clubbing, or edema. Tender, swollen
2cm mobile L inguinal LN.
PULSES: 2+ DP pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused. Area ~20cm in diameter
(demarcated with pen) of erythema with mild swelling, warm to
touch and appropriately tender to palpation, no crepitus.
Visible head of granulation tissue and eschar just below and to
the left of the umbilicus, no drainage.
DISCHARGE PHYSICAL
==================
___ 0810 Temp: 98.4 PO BP: 104/63 HR: 63 RR: 18 O2 sat: 96%
O2 delivery: RA
GENERAL: NAD
HEENT: EOMI, dry MM
HEART: RRR, S1/S2, no murmurs
LUNGS: CTAB
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema. Tender, swollen
2cm mobile L inguinal LN.
PULSES: 2+ DP pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: area of erythema (demarcated with pen) much improved, warm
and tender, no crepitus. 1x2cm eschar.
Pertinent Results:
ADMISSION LABS
==============
___ 08:03PM BLOOD WBC-9.3# RBC-4.58* Hgb-13.6* Hct-40.5
MCV-88 MCH-29.7 MCHC-33.6 RDW-12.1 RDWSD-39.3 Plt ___
___ 08:03PM BLOOD Neuts-76.2* Lymphs-16.8* Monos-5.5
Eos-0.8* Baso-0.4 Im ___ AbsNeut-7.08* AbsLymp-1.56
AbsMono-0.51 AbsEos-0.07 AbsBaso-0.04
___ 08:03PM BLOOD Glucose-82 UreaN-16 Creat-0.9 Na-139
K-4.4 Cl-99 HCO3-27 AnGap-13
___ 08:03PM BLOOD ALT-15 AST-23 CK(CPK)-190 AlkPhos-81
TotBili-0.4
___ 08:03PM BLOOD Albumin-4.6
___ 08:09PM BLOOD Lactate-0.8
MICRO
=====
Blood Cultures ___: Pending - No Growth to Date
IMAGING
=======
CT Abd and Pelvis w/ Contrast ___. Fat stranding in the anterior abdominal wall inferior to the
umbilicus
consistent with reported history of cellulitis. No abscess or
subcutaneous
gas is identified.
2. No acute process within the abdomen or pelvis.
3. Cholelithiasis without cholecystitis.
4. Dilated common bile duct to 0.8 cm without visualized
calcified stone or
mass identified. Non urgent MRCP can provide further evaluation
for
underlying etiology if desired clinically.
DISCHARGE LABS
==============
___ 05:20AM BLOOD WBC-6.6 RBC-4.48* Hgb-13.2* Hct-38.0*
MCV-85 MCH-29.5 MCHC-34.7 RDW-12.4 RDWSD-37.9 Plt ___
___ 05:20AM BLOOD Neuts-69.1 ___ Monos-7.0 Eos-2.0
Baso-0.6 Im ___ AbsNeut-4.56 AbsLymp-1.39 AbsMono-0.46
AbsEos-0.13 AbsBaso-0.04
___ 05:20AM BLOOD Glucose-103* UreaN-9 Creat-1.0 Na-140
K-4.1 Cl-101 HCO3-29 AnGap-10
___ 05:20AM BLOOD ALT-12 AST-14 LD(LDH)-111 AlkPhos-76
TotBili-0.4
Medications on Admission:
None
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
Through ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
every twelve (12) hours Disp #*9 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
Through ___.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Abdominal wall cellulitis
Secondary Diagnoses
===================
Hyperlipidemia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with ventral abdominal cellulitis, rapid spreading
inferiorly, ttp out of proportion // r/o nec fas
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 13.6 mGy (Body) DLP = 686.2
mGy-cm.
Total DLP (Body) = 693 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: There are bilateral dependent atelectasis. No focal
consolidation to suggest pneumonia. No pericardial or pleural effusions.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains gallstones at
the neck does not particularly distended. The CBD is dated to 0.8 cm without
obstructing stone or mass identified.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis in either kidney. Subcentimeter hypoattenuating
lesions in the right kidney are too small to characterize. There is no
perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Otherwise the stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. The colon and rectum are within normal limits.
The appendix is not clearly delineated though no inflammatory changes
identified.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes of the lumbar spine are mild.
SOFT TISSUES: Fat stranding in the anterior abdominal wall inferior to the
umbilicus (series 2, image 51 and series 602, image 45) is consistent with
reported history of cellulitis. No rim enhancing fluid collection is
identified. No subcutaneous gas.
IMPRESSION:
1. Fat stranding in the anterior abdominal wall inferior to the umbilicus
consistent with reported history of cellulitis. No abscess or subcutaneous
gas is identified.
2. No acute process within the abdomen or pelvis.
3. Cholelithiasis without cholecystitis.
4. Dilated common bile duct to 0.8 cm without visualized calcified stone or
mass identified. Non urgent MRCP can provide further evaluation for
underlying etiology if desired clinically.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Wound eval
Diagnosed with Cellulitis of abdominal wall
temperature: 97.1
heartrate: 95.0
resprate: 17.0
o2sat: 100.0
sbp: 138.0
dbp: 92.0
level of pain: 5
level of acuity: 3.0 | Patient is a ___ with history of depression with prior suicide
attempt complicated by exploratory laparotomy for acute abdomen
and appendectomy, anxiety, and dyslipidemia who presented with
abdominal wall erythema and pain, concerning for abdominal wall
cellulitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
morphine / Codeine / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
RECURRENT INCISIONAL HERNIA
Major Surgical or Invasive Procedure:
ventral herniography w/ mesh
History of Present Illness:
___ PMH EtOH abuse, diverticuitis s/p ___ w/ reversal, c/b
incisional hernia s/p laparoscopic mesh repair c/b recurrence,
now w/ roughly 7 days of nausea, vomiting, and abdominal pain.
He
states that the pain is worst over his known, longstanding
recurrent incisional hernia. He reports having generally been
able to stay hydrated and denies drinking alcohol for ___ years.
When his symptoms worsened, he decided to present to the ED for
treatment of his hernia and requests that his hernia be repaired
expeditiously. A CT A/P was performed in the ED which showed
herniated bowel with some evidence of intermittent
incarceration.
though no current vascular compromise or obstruction. ___
surgery was consulted for further management
Past Medical History:
DM2, HTN, HL, history of EtOH abuse, Depression.
PSH: colectectomy with colostomy, colostomy reversal, bilateral
inguinal hernia repairs
Social History:
___
Family History:
non-contributory
Physical Exam:
VS: Temp:98.2 BP:122/69 HR:77 RR16 O2:92Ra
GEN: A&Ox3, NAD, resting comfortably
HEENT: NCAT, EOMI, sclera anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, appropriately tender. Dressing CDI
EXT: warm, well-perfused, no edema
PSYCH: normal insight, memory, and mood
Pertinent Results:
___ 06:09AM BLOOD WBC-7.8 RBC-4.10* Hgb-12.7* Hct-37.3*
MCV-91 MCH-31.0 MCHC-34.0 RDW-13.1 RDWSD-43.4 Plt ___
___ 06:06AM BLOOD WBC-7.5 RBC-4.20* Hgb-13.0* Hct-38.4*
MCV-91 MCH-31.0 MCHC-33.9 RDW-13.5 RDWSD-45.6 Plt ___
___ 05:45AM BLOOD WBC-14.5* RBC-4.56* Hgb-14.2# Hct-42.1
MCV-92 MCH-31.1 MCHC-33.7 RDW-13.6 RDWSD-46.1 Plt ___
___ 11:20PM BLOOD WBC-18.0*# RBC-5.71# Hgb-17.6*#
Hct-52.0*# MCV-91 MCH-30.8 MCHC-33.8 RDW-13.4 RDWSD-45.1 Plt
___
___ 11:20PM BLOOD Neuts-89.6* Lymphs-3.5* Monos-5.9
Eos-0.4* Baso-0.3 Im ___ AbsNeut-16.16* AbsLymp-0.64*
AbsMono-1.06* AbsEos-0.07 AbsBaso-0.06
___ 06:09AM BLOOD Plt ___
___ 06:09AM BLOOD ___ PTT-PND ___
___ 06:06AM BLOOD Plt ___
___ 06:06AM BLOOD ___ PTT-27.3 ___
___ 10:18AM BLOOD ___ PTT-25.1 ___
___ 05:45AM BLOOD Plt ___
___ 11:20PM BLOOD Plt ___
___ 06:09AM BLOOD Glucose-128* UreaN-4* Creat-0.7 Na-141
K-4.3 Cl-105 HCO3-24 AnGap-12
___ 06:06AM BLOOD Glucose-124* UreaN-9 Creat-0.7 Na-142
K-4.4 Cl-108 HCO3-23 AnGap-11
___ 10:18AM BLOOD K-4.7
___ 05:45AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-142
K-5.1 Cl-105 HCO3-22 AnGap-15
___ 11:20PM BLOOD Glucose-180* UreaN-13 Creat-1.0 Na-140
K-5.2* Cl-99 HCO3-23 AnGap-18
Medications on Admission:
Denies
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
RECURRENT INCISIONAL HERNIA WITH OBSTRUCTION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ with multiple abdominal surgeries w/ abdominal pain and
vomitingNO_PO contrast// evaluate for bowel obstruction, hernia
incarceration/strangulation
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.0 s, 47.6 cm; CTDIvol = 20.0 mGy (Body) DLP = 952.8
mGy-cm.
3) Spiral Acquisition 1.1 s, 8.6 cm; CTDIvol = 11.5 mGy (Body) DLP = 99.1
mGy-cm.
4) Spiral Acquisition 0.6 s, 4.6 cm; CTDIvol = 13.5 mGy (Body) DLP = 62.7
mGy-cm.
Total DLP (Body) = 1,128 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis, right greater than left. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver dome is excluded from the study. The liver
demonstrates homogenous attenuation throughout. There is no evidence of focal
lesions. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No hydronephrosis. Bilateral subcentimeter hypodense lesions are too ___ to
characterize but likely represent cysts (2; 38). There is no perinephric
abnormality.
GASTROINTESTINAL: ___ hiatal hernia. Within a single ventral hernia, there
are loops of ___ bowel without evidence of ___ bowel enhancement or
evidence of obstruction. However, there is trace free fluid surrounding the
right lateral aspect of the loop of ___ bowel within the hernia (2; 35),
which may be suggestive of intermittent strangulation. ___ bowel loops are
normal in caliber but there appears to be relative decreasing caliber of the
___ bowel as it exits the hernia sac (2; 30). In addition, stranding of the
fat adjacent to a loop of ___ bowel (2; 27). No extraluminal or free air.
Patient is status post colectomy for diverticulitis with reversal of
colostomy. The colon is distended with fluid and air. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Compression deformity of the superior endplate of L3 is likely chronic (602;
40).
SOFT TISSUES: Single ventral hernia containing a loop of ___ bowel with neck
of the hernia measuring 3.0 cm. Patient is status post prior incisional
hernia repair. There is a left inguinal hernia containing fat.
IMPRESSION:
1. Single ventral hernia containing a loop of ___ bowel with hernia neck
measuring approximately 3.0 cm. The loop of ___ bowel within the hernia is
not dilated and has normal wall enhancement. However there is adjacent free
fluid stranding lateral to the right aspect of that loop of bowel could be
seen in the setting of intermittent incarceration.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 3:52 am, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man add-on for ventral hernia repair// pre-op cxr
Surg: ___ (ventral hernia repair) PRE-OP
IMPRESSION:
Compared to chest radiographs one ___.
Patient has had median sternotomy. Heart size is normal. Lungs are clear.
Mediastinal and hilar contours and pleural surfaces are normal.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Other and unsp ventral hernia with obstruction, w/o gangrene
temperature: 97.5
heartrate: 83.0
resprate: 16.0
o2sat: 96.0
sbp: 92.0
dbp: 57.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the General Surgical Service for
evaluation and treatment on ___. On (.___.), the
patient underwent ventral hernia repair w/ mesh, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO, on IV fluids. The patient was
hemodynamically stable.
Neuro: The patient received IV morphine with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
on ___ and at the time of discharge, the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pressure on Exertion
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
This is a ___ ___ speaking man with a history of CAD (s/p
DES to ___ at ___ ___ and DES to LCX and LMCA into
bifurcation of LAD and LCX in ___ ___, severe AS, who
presents with worsening chest pressure on exertion for the past
few days.
He reported developing chest pressure and shortness of breath
within minutes of activities such as washing dishes or walking.
He even noted it when trying to turn the steering wheel to make
a tight UTurn. The symptoms improve after severe minutes rest.
No lightheadedness, diaphoresis, chest pressure at rest,
headaches, nausea, vomiting, loss of consciousness. The time
course seems to be slowly progressive rather than acute. Given
worsening symptoms, he was sent to the ED.
In the ED initial vitals were: 97.2 77 161/74 16 98% RA
- His exam was notable for ___ SEM, mild RUQ tenderness, 1+
left, 2+ right ___ edema. Right stasis skin changes. Given RUQ
tenderness he underwent RUQ that was negative and ___ that was
also negative.
- Labs/studies notable for: Trop negative x 2. Cr 1.6 (baseline
Cr 1.4-1.5), UA was negative.
- Patient was given: Aspirin 243mg, Atenolol 100mg, Warfarin
2mg, Plavix 75mg, Losartan 50mg.
- Vitals on transfer: 98.1 72 129/60 16 98% RA
On the floor, he reports no chest discomfort and complains only
of shortness of breath with moving. Of note, he is scheduled to
see Dr. ___ on ___ for evaluation for AVR and CABG.
Past Medical History:
- Anemia
- Aortic Stenosis
- Atrial Fibrillation
- Benign Prostatic Hypertrophy
- Cerebrovascular Accident
- Chronic Kideny Disease
- Colonic Adenoma
- Coronary Artery disease s/p DES to LMCA at ___ ___ and DES
to LCX and LMCA into bifurcation of LAD and LCX in ___ ___
- Gastritis
- Glaucoma
- Glucose Intolerance
- Hyperlipidemia
- Hypertension
- Nephrolithiasis
- Osteopenia
- Spinal Stenosis
Social History:
___
Family History:
Unknown.
Physical Exam:
Admission Physical Exam:
VS: 98.2 83 18 145/68 97/RA
Weight: 71.2kg
GENERAL: In no acute distress, very pleasant. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. Dry mucous membranes. No
xanthelasma.
NECK: Supple with JVP just at the clavicle at 90 degrees.
CARDIAC: Regular rate and rhythm, II/VI systolic murmur
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use.Few bibasilar crackles,
R>L.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm, well perfused, weakly palpable pulses. 2+
edema and brawny skin changes of the right leg, 1+ of the left
NEURO: A&OX3, CN II-XII grossly intact. Gait within normal
limits.
Discharge Physical Exam:
Afebrile, otherwise unchanged.
Pertinent Results:
===============
Admission Labs:
===============
___ 05:30PM BLOOD WBC-6.4 RBC-2.78* Hgb-9.0* Hct-27.9*
MCV-100* MCH-32.4* MCHC-32.3 RDW-14.9 RDWSD-54.9* Plt ___
___ 05:30PM BLOOD ___ PTT-45.1* ___
___ 05:30PM BLOOD Glucose-103* UreaN-34* Creat-1.6* Na-141
K-3.9 Cl-104 HCO3-23 AnGap-18
___ 05:30PM BLOOD ALT-20 AST-30 AlkPhos-52 TotBili-0.8
___ 05:30PM BLOOD Lipase-77*
___ 05:30PM BLOOD cTropnT-<0.01 proBNP-2991*
===============
Discharge Labs:
===============
___ 08:50AM BLOOD WBC-5.6 RBC-3.00* Hgb-9.8* Hct-30.7*
MCV-102* MCH-32.7* MCHC-31.9* RDW-15.2 RDWSD-56.7* Plt ___
___ 08:50AM BLOOD ___ PTT-48.3* ___
___ 08:50AM BLOOD Glucose-221* UreaN-29* Creat-1.5* Na-137
K-4.5 Cl-104 HCO3-21* AnGap-17
___ 08:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 02:55PM BLOOD Albumin-4.7 Calcium-9.9 Phos-4.4 Mg-2.1
Iron-67
___ 02:55PM BLOOD calTIBC-313 Ferritn-PND TRF-241
___ 09:10AM BLOOD %HbA1c-6.4* eAG-137*
========
Imaging:
========
Right Lower Extremity US ___
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. 4.3 cm ___ cyst.
CXR ___
1. No focal consolidation.
2. Prominent interstitial markings which could represent
vascular congestion or chronic underlying interstitial process.
RUQ ___
Impression: Normal gallbladder. No intra or extrahepatic biliary
ductal dilatation.
Carotid Ultrasound ___
Read Pending
=============
Microbiology:
=============
Staph Aureus Screen ___ - Negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
3. Atenolol 100 mg PO BID
4. Vitamin D ___ UNIT PO DAILY
5. Doxazosin 2 mg PO HS
6. Furosemide 20 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Losartan Potassium 50 mg PO BID
9. Pantoprazole 20 mg PO Q12H
10. Simvastatin 20 mg PO QPM
11. Warfarin 2 mg PO DAILY16
12. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO BID
3. Doxazosin 2 mg PO HS
4. Furosemide 20 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Losartan Potassium 50 mg PO BID
7. Pantoprazole 20 mg PO Q12H
8. Simvastatin 20 mg PO QPM
9. Vitamin D ___ UNIT PO DAILY
10. Warfarin 2 mg PO DAILY16
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Severe Aortic Stenosis
Secondary Diagnosis:
- Coronary Artery Disease
- Chronic Kidney Disease
- Atrial Fibrillation
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with CAD s/p sent ___, HTN, HLD, AS being
evaluated for surgery vs. TAVR. // Carotid US to eval for stenosis
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None.
FINDINGS:
RIGHT:
The right carotid vasculature has mild heterogeneous atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 64 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 75, 83, and 64 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 29 cm/sec.
The ICA/CCA ratio is 1.3.
The external carotid artery has peak systolic velocity of 93 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild heterogeneous atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 89 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 65, 62, and 64 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 24 cm/sec.
The ICA/CCA ratio is 0.7.
The external carotid artery has peak systolic velocity of 80 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Mild bilateral heterogeneous plaque within the extracranial internal carotid
arteries. No significant stenosis bilaterally (less than 40%).
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified, Dyspnea, unspecified
temperature: 97.2
heartrate: 77.0
resprate: 16.0
o2sat: 98.0
sbp: 161.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | This is a ___ ___ speaking with a history of CAD (s/p DES
to ___ at ___ ___ and DES to LCX and ___ into bifurcation
of LAD and LCX in ___ ___, severe AS, who presents with
worsening chest pressure on exertion for the past few days.
# Chest pressure: The patient presents with worsening chest
pressure on exertion, concerning for unstable angina or symptoms
from severe AS. Troponin negative x2. BNP is elevated to 2991
but we have no recent baseline. He was diuressed with 20mg IV
lasix and then transitioned to his home dose. His symptoms were
likely due to his severe aortic stenosis. Cardiac surgery was
consulted for evaluation of aortic valve replacement. They
recommended initial studies, including carotid artery ultrasound
and several lab tests which are pending at time of discharge. He
was doing well and discharged in stable condition. He was
continued on aspirin, imdur, and statin. His plavix was held in
anticipation of upcoming surgery. He will follow-up with Cardiac
Surgery next week.
# Lower Extremity Ddema: He has bilateral lower extremity edema,
which per report is chronic. ___ negative for DVT.
# Chronic Kidney Injury: Cr currently 1.6, from baseline per
Atrius records 1.4-1.5
# Atrial fibrillation on Coumadin: Continued atenolol and
coumadin.
# Hypertension: Normotensive now. On atenolol and losartan at
baseline.
# BPH: Continued doxazosin.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
codeine
Attending: ___
Chief Complaint:
s/p fall, back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with left spastic hemiparesis from a stroke in ___ who
presented s/p mechanical fall this morning.
At baseline, he has spastic hemiparesis on the left but is able
to ambulate with a walker despite being unsteady. He lives at
home with his wife. He has a history of hoarding and his home
is
apparently quite cluttered. He has a mechanical fall this
morning and injured his back. He was not able to get up from
the
floor due to intense back pain. There was no LOC or prodromal
symptom. His wife called EMS who brought him to ___. CT
head shows expected right frontal-parietal-temporal
encephalomalacia consistent with previous stroke but there is no
evidence of bleed. C-spine was cleared at OSH. CT L-spine
revealed L1 compression fracture with 30% height loss and 1-2mm
retropulsion.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies new focal weakness,
numbness, parasthesiae. No bowel or bladder or retention though
he does have baseline incontinence (both urinary and fecal) for
years.
Past Medical History:
1. Hypertension.
2. History of carotid artery dissection.
3. Hyperlipidemia.
4. Urge incontinence.
5. Seizure disorder.
6. Depression.
7. COPD, not oxygen dependent.
8. Status post left hip hemiarthroplasty.
9. History of PFO.
10. Short-term memory loss.
11. Atypical chest pain.
12. History of recurrent cellulitis on the left foot.
13. History of MRSA infection.
14. History of stroke with left-sided hemiparesis in ___.
15. Tinea pedis.
16. History of alcohol abuse.
17. Bipolar disorder.
18. History of pulmonary nodules.
19. Lower extremity edema.
Social History:
___
Family History:
His mother had ___ disease, and his father died of an
MI. He has a sister with rheumatoid arthritis
Physical Exam:
On Admission:
Vitals: T: 98.2 P: 96 R: 18 BP: 151/106 SaO2: 93%RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Spine: midline tenderness in the upper lumbar region.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Grossly attentive. Language is fluent with
intact comprehension. Normal prosody. There were no paraphasic
errors. Pt was able to name both high and low frequency objects.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5 mm and brisk. VFF to confrontation. No visual
extinction on DSS.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left face droop, though activation is more or less
symmetric
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk throughout. Normal rectal tone (per ED
resident) Spastic on the left hemibody. Left arm contracted. No
pronator drift on the right.
He has action and postural tremors.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 4 5 0 0 0 0 3 0 0 0 0 0
R 5 ___ ___ 5 5 5 5 5
-Sensory: Decreased but present light touch, pinprick in the
left
hemibody. Normal on the right. No saddle anesthesia (per ED
resident)
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 4 4
R 2 2 2 2 1
Plantar response was flexor on the right and extensor on the
left.
-Coordination: No dysmetria on the right arm and leg. Unable to
test left arm and leg due to weakness.
-Gait: Deferred
On Discharge:
AAO x 3. Baseline L face droop and L spastic hemiparesis. Full
on the right. Also left hemi-sensory deficit (decreased but
present). LUE contracted; LLE antigravity. Midline tenderness in
the upper lumbar spine. Rectal tone normal. No saddle
anesthesia.
Pertinent Results:
HIP UNILAT MIN 2 VIEWS LEFT ___
No acute fracture
CXR ___ As compared to the previous radiograph, the lung
volumes have decreased. Areas
of atelectasis are seen at the right lung basis. However, there
is no evidence
of pneumonia or pulmonary edema. No larger pleural effusions.
Normal size of
the cardiac silhouette. Normal hilar and mediastinal contours.
___ MRI L spine
Acute compression fracture of the L1 vertebral body with mild
retropulsion of
the dorsal cortex into the spinal canal causing mild to moderate
narrowing of
the thecal sac, but no compression of the conus medullaris.
___ CXR
Mild pulmonary edema, increased from prior study.
___hronic occlusion of the right proximal ICA with reconstitution
in the distal ICA as well as the intracranial segment which is
small and
thread-like in caliber. No acute infarction.
___ CT chest/abdomen/pelvis
1. No evidence of hemorrhage in the chest, abdomen, or pelvis.
2. Moderate
emphysema. 3. Multiple pulmonary nodules, the largest which
measures 6 mm.
Recommend a repeat chest CT in 6 months. 4. L1 compression
fracture, better
evaluated on the recent MRI. 5. Probable median arcuate ligament
syndrome.
Recommend correlation with symptoms.
___ CXR
Comparison is made to prior study from ___.
The heart size is upper limits of normal but stable. There is
again seen
minimal pulmonary edema and some atelectasis at the lung bases.
There are no pneumothoraces.
___ BLE LENIS
No evidence of DVT in the bilateral lower extremities.
___ EEG:
Abnormal continuous EEG because of (1) Nearly continuous right
temporal discharges, occurring periodically up to every one to
three seconds, consistent with marked focal cortical
irritability; and (2) right hemispheric slowing, most prominent
in the temporal leads, consistent with focal dysfunction. There
were no organized electrographic seizures.
___ MRI/MRA
1. Chronic infarction, causing extensive area of
encephalomalacia involving the right middle cerebral artery
territory as described in detail above, causing
encephalomalacia, ex vacuo dilatation of the lateral ventricle,
and asymmetry of the right cerebral peduncle.
2. Occlusion of the right proximal internal carotid artery, with
collateral flow via the external carotid artery and right
posterior communicating artery. No aneurysms are identified.
___ 03:30PM BLOOD WBC-6.6 RBC-3.63* Hgb-12.0* Hct-36.5*
MCV-101* MCH-33.0* MCHC-32.7 RDW-12.7 Plt ___
___ 03:30PM BLOOD ___ PTT-35.5 ___
___ 03:30PM BLOOD Glucose-103* UreaN-13 Creat-0.8 Na-142
K-4.2 Cl-107 HCO3-30 AnGap-9
___ 03:45PM BLOOD ALT-22 AST-21 LD(LDH)-200 AlkPhos-66
TotBili-0.2
___ 03:30PM BLOOD Calcium-8.7 Phos-2.2* Mg-1.9
___ 06:55PM BLOOD Carbamz-7.7
Medications on Admission:
He endorses taking ASA 81 daily
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aripiprazole 30 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Benzonatate 100 mg PO QID:PRN cough
5. Carbamazepine 200 mg PO QAM
6. Carbamazepine 400 mg PO QHS
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. HydrALAzine 10 mg PO BID
9. LaMOTrigine 200 mg PO BID
10. Lisinopril 40 mg PO DAILY
11. Mirtazapine 15 mg PO HS
12. Simvastatin 40 mg PO DAILY
13. Tamsulosin 0.4 mg PO BID
14. Venlafaxine XR 150 mg PO DAILY
15. Ketoconazole 2% 1 Appl TP BID
RX *ketoconazole 2 % Apply to bilateral toes, webspaces, and
feet twice a day Disp #*1 Tube Refills:*0
16. LOPERamide 2 mg PO QID:PRN constipation
17. lactobacillus acidophilus 1 pill oral bid
18. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
___
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every eight (8) hours Disp #*25 Tablet Refills:*0
19. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Aripiprazole 30 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Carbamazepine 200 mg PO DAILY
6. Carbamazepine 400 mg PO QHS
7. Ciprofloxacin HCl 250 mg PO Q12H Duration: 5 Days
8. Docusate Sodium 100 mg PO BID
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Heparin 5000 UNIT SC TID
11. Ketoconazole 2% 1 Appl TP BID
12. LaMOTrigine 200 mg PO BID
13. LeVETiracetam 1000 mg PO BID
14. Mirtazapine 15 mg PO HS
15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
16. Senna 17.2 mg PO BID
17. Simvastatin 40 mg PO DAILY
18. Tamsulosin 0.4 mg PO HS
19. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L1 compression fracture
Right temporal epileptiform discharges
Multiple pulmonary nodules
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fall, left hip pain // ?fracture
TECHNIQUE: AP view of the pelvis and AP and cross-table lateral views of the
left hip.
COMPARISON: ___
FINDINGS:
There is no visualized acute fracture. Left hip bipolar hemiarthroplasty is
seen without evidence of periprosthetic lucency or fracture. There is no
dislocation.
IMPRESSION:
No acute fracture.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p fall, desat to 79%. // ?atelactasis,
pna.
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the lung volumes have decreased. Areas
of atelectasis are seen at the right lung basis. However, there is no evidence
of pneumonia or pulmonary edema. No larger pleural effusions. Normal size of
the cardiac silhouette. Normal hilar and mediastinal contours.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST
INDICATION: ___ year old man with s/p fall with L1 compression fracture.
Evaluate for abnormal cord signal/ hematoma/ infarct
TECHNIQUE: Multiplanar, multi sequence MR images of the lumbar spine were
obtained.
COMPARISON: CT lumbar spine ___.
FINDINGS:
There is an acute compression fracture of the L1 vertebral body (less than 50%
loss of height) with retropulsion of the dorsal cortex into the spinal canal,
causing mild to moderate narrowing of the thecal sac, but no compression of
the conus medullaris. The posterior longitudinal ligament is disrupted. No
other fracture or abnormal bone marrow signal is identified.
Lumbar spine alignment is preserved. The remainder of the vertebral body
heights and disc spaces are maintained. There are mild multilevel degenerative
changes without significant spinal canal or neural foraminal narrowing.
Atrophy of the left psoas muscle is noted.
The conus medullaris is normal in morphology and signal intensity and
terminates at the level of L1-L2. No large epidural hematoma is identified.
IMPRESSION:
Acute compression fracture of the L1 vertebral body with mild retropulsion of
the dorsal cortex into the spinal canal causing mild to moderate narrowing of
the thecal sac, but no compression of the conus medullaris.
Radiology Report
INDICATION: Low O2 sats, evaluate for congestion.
COMPARISON: ___.
FINDINGS: AP portable view of the chest. Low lung volumes. Compared to
prior study, there is an increase in pulmonary edema. No significant pleural
effusion. No pneumothorax. Cardiomediastinal and hilar contours are stable.
IMPRESSION: Mild pulmonary edema, increased from prior study.
Radiology Report
TECHNIQUE: CTA of the head and neck with contrast.
HISTORY: Dysarthria and confusion.
COMPARISON: ___.
FINDINGS: On the unenhanced scan, there is encephalomalacia in the right MCA
territory with changes from a prior craniotomy. There is a chronic-appearing
subdural collection with calcifications within the neck. There is occlusion
of the right proximal ICA with reconstitution distally of a thread-like ICA
via collaterals with continued thread-like opacification of the intracranial
ICA. There is diminution of the right MCA branches and prominent ECA
collaterals.
Evaluation of the left ICA demonstrates no aneurysm or high-grade stenosis.
There is a hypoplastic right A1 segment. In the neck, the left carotid artery
demonstrates no significant stenosis. Bilateral vertebral arteries are
patent.
There are chronic lung changes of emphysema and opacities at the lung apices.
IMPRESSION: Chronic occlusion of the right proximal ICA with reconstitution
in the distal ICA as well as the intracranial segment which is small and
thread-like in caliber. No acute infarction.
Radiology Report
INDICATION: New onset dysarthria, confusion, hypotension, and dropping
hematocrit. Evaluate for hemorrhage.
TECHNIQUE: MDCT axial images were obtained through the torso after the
administration of IV contrast. Sagittal and coronal reformatted images were
obtained and reviewed.
DOSE: DLP: 1161.95 mGy-cm.
COMPARISON: MRI of the lumbar spine from ___. Pelvic CT from ___.
FINDINGS:
CHEST: The imaged portions of the thyroid gland are normal. There is no
axillary, mediastinal, or hilar lymphadenopathy. The heart is normal size.
Trace pericardial fluid is within the normal physiologic range. The thoracic
aorta is normal in caliber without evidence of acute aortic pathology. There
are no significant atherosclerotic calcifications. The main pulmonary artery
trunk is mildly dilated, measuring 3.5 cm. This suggests mild underlying
pulmonary hypertension.
The airways are patent to the subsegmental levels. Evaluation of the pulmonary
parenchyma is limited by respiratory motion and moderate bibasilar dependent
atelectasis. Moderate emphysematous changes are noted. There are several sub 4
mm pulmonary nodules in the right middle lobe (2; 22, 24, and 25). There is a
6 mm pleural-based nodule in the right lower lobe (2, 26). There is no
pulmonary edema or focal airspace consolidation to suggest pneumonia. There is
no pleural effusion or pneumothorax.
ABDOMEN: The liver is normal in shape and contour. There are no focal hepatic
lesions. The portal veins are patent. The gallbladder is mildly distended, but
there is no CT evidence of cholecystitis. The spleen pancreas, and adrenal
glands are normal. In the lower pole of the left kidney, there is a 23 mm
cyst. No other renal lesions are identified. There is no hydronephrosis or
pyelonephritis. The kidneys enhance and excrete contrast symmetrically.
The stomach and small bowel are normal in caliber. There is no evidence of
obstruction, free air or free fluid. There is no retroperitoneal hematoma.
There is no periportal, retroperitoneal, or mesenteric lymphadenopathy. The
origin of the celiac artery is compressed by the diaphragmatic crus with
moderate to severe narrowing and post stenotic dilation. There is no
atherosclerotic disease. This finding can be seen in median arcuate ligament
syndrome. The remainder of the arterial vasculature is normal with trace
atherosclerotic calcifications.
PELVIS: Evaluation of the pelvis is limited by metallic artifact from the left
total hip arthroplasty. Within the limitations, the imaged portions of the
large bowel are normal without focal inflammatory changes or evidence of a
mass. A Foley catheter is present within the bladder. The bladder and
prostate are otherwise unremarkable. There is no free fluid in the pelvis.
There is no pelvic or inguinal lymphadenopathy.
There is evidence of a prior abdominal wall hernia repair in the right lower
quadrant. Soft tissue stranding in the anterior abdominal wall fat is likely
from recent subcutaneous injections.
OSSEOUS STRUCTURES: The patient is status post a total left hip arthroplasty.
There are old healing fractures in the left superior and inferior pubic rami.
A compression fracture of L1 is better evaluated on the recent MRI of the
lumbar spine. No other compression fractures are identified. There are no
concerning lytic or sclerotic osseous lesions.
IMPRESSION:
1. No evidence of hemorrhage in the chest, abdomen, or pelvis. 2. Moderate
emphysema. 3. Multiple pulmonary nodules, the largest which measures 6 mm.
Recommend a repeat chest CT in 6 months. 4. L1 compression fracture, better
evaluated on the recent MRI. 5. Probable median arcuate ligament syndrome.
Recommend correlation with symptoms.
Radiology Report
EXAMINATION: MRI and MRA Head, MRA of the neck.
INDICATION: ___ year old man with MS change // stroke? please perform DWI
sequence
TECHNIQUE: Multi planar multi sequence MR images of the brain were obtained
with and without contrast, including axial and sagittal FLAIR sequence, axial
T2, axial T1, axial magnetic susceptibility and axial diffusion-weighted
images. The T1 weighted images were repeated after the administration of
gadolinium contrast in axial T1, sagittal MP-RAGE with multiplanar
reconstructions.
MRA of the head, non contrast 3D time-of-flight MRA of the brain was
performed, maximal intensity projection images and multiplanar reconstructions
were reviewed.
COMPARISON: CTA of the head and neck dated ___. Prior head CT
without contrast dated ___.
FINDINGS:
MR Head: Th there is an extensive area of encephalomalacia in the vascular
territory of the right middle cerebral artery, causing ex vacuo dilatation of
the lateral ventricle and asymmetry of the right cerebral peduncle. No
diffusion abnormalities are detected to suggest acute or subacute ischemic
changes. The patient is status post right frontal parietal craniotomy. There
is a chronic appearing subdural collection with mild enhancement along the
right frontal temporal region mild no significant mass effect, unchanged since
the prior head CT dated ___. The examination is partially limited due
to patient motion On the axial images without contrast, there is a punctate
focus of enhancement in the pons (image 8, series 17), likely artifactual,
which is not visible in other sequence. The vascular flow void of the right
internal carotid is not detected, likely consistent with chronic conclusion.
MRA Head: There is occlusion of the right proximal internal carotid artery,
apparently there is reconstitution of the distal branches via collateral flow
from the right external carotid artery and right posterior communicating
artery. The vascular signal throughout the right middle severe artery appears
decreased. The basilar artery appears patent as well as the vertebral
arteries, the left internal carotid artery is tortuous with mild narrowing of
the distal middle cerebral artery, suggesting arteriosclerotic disease, the
right posterior cerebral artery appears patent with fetal origin. No aneurysms
are identified.
IMPRESSION:
1. Chronic infarction, causing extensive area of encephalomalacia involving
the right middle cerebral artery territory as described in detail above,
causing encephalomalacia, ex vacuo dilatation of the lateral ventricle, and
asymmetry of the right cerebral peduncle.
2. Occlusion of the right proximal internal carotid artery, with collateral
flow via the external carotid artery and right posterior communicating artery.
No aneurysms are identified.
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ male with pulmonary edema. Worsening
infiltrate.
FINDINGS: Comparison is made to prior study from ___.
The heart size is upper limits of normal but stable. There is again seen
minimal pulmonary edema and some atelectasis at the lung bases. There are no
pneumothoraces.
Radiology Report
INDICATION: ___ male with mental status change. Evaluate for
evidence of DVT.
COMPARISON: Bilateral lower extremity ultrasonographic examination of the
veins from ___.
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation was performed on
the bilateral lower extremity veins.
FINDINGS: Significant soft tissue edema in the left lower extremity limits
exam of the left calf. There is normal compressibility, flow, and augmentation
of the bilateral common femoral, proximal superficial femoral, mid superficial
femoral, distal superficial femoral, and popliteal veins bilaterally. Normal
color flow and compressibility was obtained of the right posterior tibial and
peroneal veins. Wall-to-wall flow is seen in the left posterior tibial and
peroneal veins, but no compressibility could be assessed due to significant
lower extremity edema.
IMPRESSION: No evidence of DVT in the bilateral lower extremities.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: s/p Fall, L1 COMPRESSION FX
Diagnosed with FX LUMBAR VERTEBRA-CLOSE, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT
temperature: 98.2
heartrate: 96.0
resprate: 18.0
o2sat: 93.0
sbp: 151.0
dbp: 106.0
level of pain: 9
level of acuity: 2.0 | Mr. ___ is a ___ y/o M s/p mechanical fall presents with L1
compression fracture. He was admitted to neurosurgery for
further management. A TLSO brace was ordered and was measured
for brace. On ___, TLSO arrived. He had low urine output and a
500cc bolus was given. ___ was consulted as well.
On ___, patient was neurologically stable on examination in the
AM. MRI L-spine was completed and showed PLL injury. TLSO brace
was ordered to be worn when HOB>30 degrees and when OOB. He
developed hypotension with a systolic of 88, 500cc bolus was
given. He continued to be hypotensive with a systolic 69. He was
placed in reverse Trendelenburg and began to desaturate. He also
became dysarthric and lethargic. His O2 was increased to 5L. ABG
was performed and was normal. Labs were sent and showed
significant decrease in hct and plt count. Medicine was
consulted. CXR was performed and showed some congestion. He was
given an additional liter of fluid for continued hypotension.
Neuro stroke was consulted for concern of stroke. Medicine
recommendations were to transfer patient to the ICU and obtain
CTA head, neck, chest, abdomen, and pelvis. Hematology was
consulted for question of HIT. SQH and aspirin were held.
He was transferred to the ICU after CTAs were preformed. Repeat
labs showed improvement in hct and plt. He was restarted on SQH
and aspirin given the erroneous labs and decreased risk of HIT.
Neuro stroke recommended EEG, tegretol and lamictal levels, and
discontinuing antihypertensives.
On ___ Patient was normotensive and O2 sats were WNL. He was
neurologically stable. Patient was transferred to the floor with
telemetry. CXR revealed minimal pulmonary edema and some
atelectasis at the lung bases. BLE dopplers revealed no evidence
of DVT in the bilateral lower extremities.
On ___ routine EEG shows L temporal periodic discharges.
Patient was loaded with Keppra 1g then started on 750mg BID.
On ___ EEG positive for epileptiform discharges, but no active
seizures. Keppra was increase to 1000mg BID. EEG lead were
removed.
On ___, ___ evaluated the patient and was unable to work with him
due to back pain. His pain regimen was increased.
On ___, patient was unchanged. He had a positive U/A and was
started on cipro.
Mr. ___ was discharged to a rehabilitation facility on ___.
As discussed in the discharge summary paperwork, the patient
should follow up with Neurosurgery, Neurology and his PCP.
Because of new-found pulmonary nodules on a chest CT, radiology
recommended that he have follow-up screening by his PCP in
approximately ___ months.
At the time of discharge, Mr. ___ was afebrile,
hemodynamically and neurologically stable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right second toe ulceration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with known peripheral arterial disease noticed
an ulcer on his right second toe that progressively had became
more painful, black and swollen.
He presents to the ER for evaluation.
Past Medical History:
PMH: HTN, dyslipedmia, CAD s/p LAD stent (___) c/b coronary
perf requiring coil embolization, mild AR, hypothyroidism
PSH: ___ b/l ___ angiogram with PTA and stenting of L EIA
(Dr. ___, b/l knee replacements
Physical Exam:
Physical Exam:
Alert and oriented x 3 although short term memory is poor.
VS:BP 118/60 HR 78 RR 16
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Left Femoral dop, DP dop ,___ dop
Right Femoral dop, DP - ,___ -
Feet warm. Right second toe edematous, tender and darkly
discolored. Dry eschar 3mm x 3mm on tip of right second toe.
Pertinent Results:
___ 12:23PM BLOOD WBC-4.7 RBC-3.78* Hgb-12.4* Hct-36.4*
MCV-96 MCH-32.8* MCHC-34.1 RDW-13.7 RDWSD-48.1* Plt ___
___ 07:15AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-135
K-3.8 Cl-102 HCO3-23 AnGap-14
___ 07:15AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.9
ABI/PVR ___
FINDINGS:
On the right, the femoral and popliteal waveforms are monophasic
and the
posterior tibial and dorsalis pedis Doppler waveforms are absent
at the ankle. The digit waveform is flat. .
The right ABI was not obtainable due to absence of Doppler
signals..
On the left side, the femoral waveform was triphasic but the
popliteal and tibial waveforms were monophasic. The PPG digit
waveform was flat. The left ABI was not obtainable due to
noncompressible vessels.. The left great toe pressure is 33 mm
of mercury yielding a TBI of 0.24.
Pulse volume recordings showed symmetric amplitudes bilaterally
at all level with flat waveforms at the metatarsal level.
IMPRESSION: Evidence of right ileo-femoral and left
femoral-popliteal occlusive disease with severe ischemia
Right Foot Xray: ___
IMPRESSION:
No radiographic evidence of osteomyelitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Moexipril 15 mg PO BID
2. Carvedilol 12.5 mg PO BID
3. Chlorthalidone 25 mg PO DAILY
4. Rosuvastatin Calcium 20 mg PO QPM
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Chlorthalidone 25 mg PO DAILY
4. Moexipril 15 mg PO BID
5. Rosuvastatin Calcium 20 mg PO QPM
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Arterial Disease with ulceration
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with PVD and new ulcer at tip of second toe presenting with
worsening pain at the toe, erythema and warmth. // Please evaluate for
evidence of osteomyelitis.
TECHNIQUE: Three views of the right foot.
COMPARISON: None.
FINDINGS:
Moderate to severe degenerative changes seen at the first metatarsophalangeal
joint. Osseous structures are otherwise unremarkable without focal erosions.
Joint spaces are otherwise preserved. Small vessel atherosclerotic
calcifications are noted.
IMPRESSION:
No radiographic evidence of osteomyelitis.
Radiology Report
INDICATION: ___ former smoker w/ PAD b/l iliac disease s/p L EIA stent
___, lost of f/u now p/w 1 month nonhealing ___ toe ulcer // Please
evaluate ABIs, PVRs
TECHNIQUE: Non-invasive evaluation of the arterial system in the
lower extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
COMPARISON: None
FINDINGS:
On the right, the femoral and popliteal waveforms are monophasic and the
posterior tibial and dorsalis pedis Doppler waveforms are absent at the ankle.
The digit waveform is flat. .
The right ABI was not obtainable due to absence of Doppler signals..
On the left side, the femoral waveform was triphasic but the popliteal and
tibial waveforms were monophasic. The PPG digit waveform was flat. .
The left ABI was not obtainable due to noncompressible vessels.. The left
great toe pressure is 33 mm of mercury yielding a TBI of 0.24.
Pulse volume recordings showed symmetric amplitudes bilaterally at all level
with flat waveforms at the metatarsal level.
IMPRESSION:
Evidence of right ileo-femoral and left femoral-popliteal occlusive disease
with severe ischemia
Radiology Report
EXAMINATION: VENOUS MAPPING
INDICATION: ___ former smoker w/ PAD b/l iliac disease s/p L EIA stent
___, lost of f/u now p/w 1 month nonhealing ___ toe ulcer // Please
evaluate for conduit
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
RIGHT: The cephalic vein is patent with measurements of 0 point 1 5
proximally to 0.12 cm distally. The basilic vein is patent with measurements
of 0.15 cm proximally to 0.22 cm distally
LEFT: The cephalic vein is patent with measurements of 0.13 cm proximally to
0.07 cm distally. There is an IUD in a within a thick-walled segment at the
antecubital fossa. The basilic vein is patent with measurements of 0.15-0.12
cm.
IMPRESSION:
Patent cephalic and basilic veins bilaterally with small diameters. Please
see the scanned vascular worksheet for a detailed diameters.
Radiology Report
EXAMINATION: VENOUS MAPPING
INDICATION: ___ former smoker w/ PAD b/l iliac disease s/p L EIA stent
___, lost of f/u now p/w 1 month nonhealing ___ toe ulcer // Please
evalaute for conduit
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of bilateral
lower extremity veins.
COMPARISON: None.
FINDINGS:
RIGHT: The great saphenous vein is patent with diameters ranging from 0.47 to
0. 3 4 cm. The right small saphenous vein is patent with diameters ranging
from 0.45 to 0.41 cm.
LEFT: The great saphenous vein is patent with diameters ranging from 0.31 to
0.18 cm. The left small saphenous vein is patent with diameters ranging from
0.29 to 0.15 cm. Calcification is noted in the distal lesser saphenous vein.
IMPRESSION:
The great and small saphenous veins are patent bilaterally. Please see
digitized image on PACS for formal sequential measurements.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ male former smoker with peripheral tear disease
bilateral iliac disease status post right external iliac artery stent on ___. The patient was lost to follow-up not presents with a
one-month non healing right second toe ulcer an worsening pain.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast, arterial, portal venous and
delayed phase images were acquired through abdomen and pelvis
Oral contrast was not administered
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DLP: 3889 mGy-cm (abdomen and pelvis).
IV Contrast: 130 mL of Omnipaque
COMPARISON: CT from ___.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is diffuse atherosclerotic
disease involving the abdominal aorta, bilateral iliac arteries and lower
extremity arteries. Calcified atherosclerotic disease is noted in the
bilateral common femoral arteries causing approximate 50% stenosis. Diffuse
atherosclerotic disease of the bilateral superficial femoral artery causing
multilevel significant stenosis and occlusion to the level of the popliteal
arteries bilaterally is unchanged. There is extensive atherosclerotic disease
and multiple areas of stenoses of the tibial vessels with three vessel runoff
on the left, two vessel runoff on the right (peroneal and posterior tibial)..
LOWER CHEST: The visualized lung bases are clear without focal consolidation,
pleural effusion or pneumothorax. The heart is normal in size without
pericardial effusion. Coronary artery calcifications are noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Multiple bilateral renal cysts are noted. The kidneys have normal
nephrograms. A left renal defect is again noted, likely reflective of prior
ischemic insult. There is no evidence of stones or hydronephrosis. There are
no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Diverticulosis is noted without evidence of
diverticulitis. . There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Prostate is enlarged.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is
within normal limits.
IMPRESSION:
Diffuse atherosclerotic disease involving the abdominal aorta, iliac arteries
and lower extremity runoff as described above. Heavy atherosclerotic
calcifications cause stenosis and eventual occlusion of the superficial
femoral arteries to the level of the popliteal arteries bilaterally. The
popliteal arteries are difficult to identify due to bilateral total knee
replacements.Though extensive atherosclerotic disease and multiple areas of
stenoses, the three vessel runoff appears on the left, two vessel runoff on
the right.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Toe pain
Diagnosed with CIRCULATORY DISEASE NEC
temperature: 97.8
heartrate: 85.0
resprate: 18.0
o2sat: 98.0
sbp: 125.0
dbp: 76.0
level of pain: 7
level of acuity: 3.0 | ___ year old man with known peripheral arterial disease noticed
an ulcer on his right second toe that progressively had became
more painful, black and swollen.
He presents to the ER for evaluation. As right ___ pulses were
not dopplerable, we obtained ABI/PVR which showed the femoral
and popliteal waveforms are monophasic and the posterior tibial
and dorsalis pedis Doppler waveforms are absent at the ankle.
Metatarsal waveforms are flat.
Further workup showed no evidence of osteo in the right second
toe. He did not require pain medication and had no systemic
infection with normal temp and wbc. Vein mapping showed
excellent RLE conduit for bypass. Given these finding we will
discharge him to home to return for angiogram within the next
week secondary to no OR availability.
He was discharged to home with family, ambulatory at baseline
with a cane on all home medication. We will start him on
bactrim prophalaxtically for the next week until angiogram
scheduled for ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking female presents with lower back and
neck pain with associated bilateral hand numbness. She is
currently displaced from ___ due to the hurricane. She
says that during the hurricane, she was using a bucket to try to
get water out of her house when she strained her back and her
lower back pain got much worse. Since that time she says she has
had to sleep sitting up because of the pain. The pain does not
radiate down from her back and she denies any radicular symptoms
of the bilateral lower extremities. She is also having numbness
of both hands, R > L but is currently denying neck pain. She
says
the neck pain has basically resolved. Her hand numbness is
isolated to her hands and is generalized, without specific
finger
distribution. No bowel or bladder incontinence. Otherwise denies
gait instability, loss of dexterity, change in handwriting,
tripping, falling, dizziness, vision changes, chest pain,
shortness of breath, nausea or vomiting.
Past Medical History:
HTN, MI, CAD s/p cardiac cath (in ___ with unknown
stent placement
Social History:
___
Family History:
Non contributory
Physical Exam:
On Admission:
=============
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
Right5 5 5 5 5
Left5 5 5 5 5
IPQuadHamATEHLGast
Right5 5 5 5 5 5
Left5 5 5 5 5 5
[x]Sensation intact to light touch
On Discharge:
=============
GENERAL: NAD
HEENT: PERRL, EOMI; no LAD in neck axilla or groin
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no w/r/c, no accessory muscle use
ABDOMEN: obese, soft NTND
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, no FND on exam, sensory intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 03:40PM BLOOD WBC-7.0 RBC-4.40 Hgb-13.8 Hct-43.7
MCV-99* MCH-31.4 MCHC-31.6* RDW-13.4 RDWSD-48.7* Plt ___
___ 03:40PM BLOOD Neuts-67.4 ___ Monos-8.9 Eos-1.4
Baso-0.1 Im ___ AbsNeut-4.72 AbsLymp-1.53 AbsMono-0.62
AbsEos-0.10 AbsBaso-0.01
___ 03:40PM BLOOD ___ PTT-31.7 ___
___ 03:40PM BLOOD Plt ___
___ 03:40PM BLOOD Glucose-102* UreaN-19 Creat-0.7 Na-141
K-6.1* Cl-101 HCO3-27 AnGap-13
DISCHARGE LABS:
===============
___ 07:30AM BLOOD WBC-6.0 RBC-4.14 Hgb-12.9 Hct-40.1 MCV-97
MCH-31.2 MCHC-32.2 RDW-13.2 RDWSD-47.4* Plt ___
___ 07:30AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-30.4 ___
___ 05:15AM BLOOD Glucose-99 UreaN-15 Creat-0.6 Na-143
K-3.7 Cl-101 HCO3-29 AnGap-13
___ 05:15AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0
MRI:
====
GENERAL: NAD
HEENT: PERRL, EOMI; no LAD in neck axilla or groin
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no w/r/c, no accessory muscle use
ABDOMEN: obese, soft NTND
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, no FND on exam, sensory intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
CT:
===
9 mm right upper lobe nodule is suspicious for malignancy given
the presence
of right hilar and mediastinal lymphadenopathy. Options for
follow-up include
an FDG PET-CT now or repeat chest CT in 3 months.
Attention should also be paid to a 6 mm left upper lobe nodule
on follow-up
imaging.
Mild pulmonary edema.
Compression fracture of the T7 vertebral body with 50% height
loss is more
completely assessed on thoracic spine MRI of ___.
No additional
fractures in the thoracic spine or rib cage.
10 mm left breast nodule is incompletely evaluated on this
study. Recommend
mammography if it has not been recently performed.
Please see the separately dictated CT abdomen and pelvis report
from the same
date for description of subdiaphragmatic findings.
RECOMMENDATION(S): FDG PET-CT now or chest CT in 3 months for
continued
assessment of 9 mm right upper lobe pulmonary nodule.
Medications on Admission:
- Ramipril 2.5 mg tablet, 1 tab PO daily
- Metoprolol succinate ER 50 mg tablet,extended release 24 hr
oral
1 tablet extended release 24 hr(s) Once Daily
- Omeprazole 40 mg capsule,delayed release oral, 1 capsule PO
daily
- Atorvastatin 40 mg tablet oral, 1 tab PO daily
- Aspirin 81 mg tablet oral 1 tab PO daily
- Diclofenac potassium 50 mg tablet oral, 1 tab PO daily
- Nitroglycerin 0.4 mg sublingual tablet sublingual, 1 tab PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 capsule(s) by mouth every eight (8)
hours Disp #*60 Capsule Refills:*0
2. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half)
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Furosemide 20 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Omeprazole 40 mg PO DAILY
9. Ramipril 2.5 mg PO DAILY
10. HELD- Diclofenac Sodium ___ 50 mg PO BID This medication was
held. Do not restart Diclofenac Sodium ___ ___ directed by your
new PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
T7 and L1 Compression Fracture
Lung nodule
Breast nodule
Vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE.
INDICATION: ___ year old woman with neck pain, complaint of arm weakness//
Cord compression, disc herniation.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of 7 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: CT lumbar spine ___.
FINDINGS:
CERVICAL:
There is no evidence of vertebral body height loss within the cervical spine.
There is minimal, 1-2 mm of retrolisthesis of C5 on C6 and C6 on C7. The bone
marrow signal is normal.
There is a background of minimal congenital cervical spinal canal narrowing,
which combines with degenerative changes as follows:
C1-C2, C2-C3: There is no definite spinal canal stenosis or neural foraminal
narrowing.
C3-C4: There is a minimal posterior disc bulge which results in mild canal
stenosis with uncovertebral joint hypertrophy resulting in moderate bilateral
neural foraminal narrowing.
C4-C5: A posterior disc bulge flattens the ventral thecal sac resulting in
mild-to-moderate canal stenosis with moderate bilateral neural foraminal
narrowing.
C5-C6: A posterior disc bulge results in moderate canal stenosis with mild
right and moderate left neural foraminal narrowing.
C6-C7: A posterior disc bulge indents the ventral thecal sac resulting in
moderate canal stenosis with uncovertebral joint hypertrophy resulting in mild
right and mild-to-moderate left neural foraminal narrowing.
C7-T1: There is a minimal disc bulge at this level with no significant canal
stenosis and with mild left neural foraminal narrowing. Small bilateral
perineural cysts are seen.
THORACIC SPINE:
There is a severe compression fracture involving the T7 vertebral body with
mild increased STIR signal, which may reflect a subacute fracture. No
significant bony retrolisthesis or retropulsion is seen at this level. The
remainder of the thoracic vertebral bodies demonstrate normal height.
The sagittal spinal alignment is grossly maintained. There is no suspicious
bone marrow signal identified.
A mild posterior disc bulge is seen at T7-T8 which indents the ventral thecal
sac resulting in mild canal stenosis. Otherwise, no significant spondylosis
is seen within the thoracic spine.
LUMBAR:
There is an acute appearing fracture with severe compression of the L1
vertebral body, with approximately 4 mm of bony retropulsion of the largest
fracture fragment. This results in mild thecal sac indentation and canal
stenosis at this level, with patent neural foramina bilaterally.
Otherwise, the remainder of the lumbar vertebral bodies demonstrate normal
height and alignment. There is no concerning focal bone marrow signal
abnormality. The conus medullaris terminates at the level of L1.
There is a small posterior disc bulge at L5-S1 with no canal stenosis and mild
left neural foraminal narrowing. Of note, the disc bulge at this level
minimally contacts the exiting left L5 nerve root. A left-sided perineural
cyst is also noted at this level. Otherwise, minimal posterior disc bulging
at L2-3, L3-4, L4-5 are seen without significant canal stenosis or neural
foraminal narrowing.
There is no evidence for abnormal intramedullary or epidural enhancement.
There is fatty atrophy of the bilateral paraspinal musculature. Otherwise,
the visualized paraspinal soft tissues are grossly unremarkable in appearance.
IMPRESSION:
1. Severe compression fracture of the T7 vertebral body, likely subacute and
without significant retropulsion.
2. Acute appearing, severe compression fracture of L1 with mild bony
retropulsion causing mild canal stenosis. No evidence for epidural
collection, hematoma, or abnormal enhancement.
3. Posterior disc bulges at C5-6 and C6-7 resulting in moderate canal
stenosis.
4. Multiple additional levels of background spondylosis throughout the
cervical, thoracic, and lumbar spine, as detailed above.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:11 am, 20 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with multiple vertebral compression
fractures.// CT torso with and without to evaluate for fractures and
malignancy
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 64.1 cm; CTDIvol = 17.7 mGy (Body) DLP =
1,132.3 mGy-cm.
2) Stationary Acquisition 6.1 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP =
16.8 mGy-cm.
Total DLP (Body) = 1,149 mGy-cm.
COMPARISON: Reportedly with recent MR of the spine. No prior CT abdomen for
comparison.
FINDINGS:
The exam is limited due to excessive motion.
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN: The liver demonstrates multiple hypodense lesions some of which are
cysts while others are too small to characterize. The gallbladder is within
normal limits. There is no biliary ductal dilatation. The pancreas, adrenal
glands, spleen and kidneys are unremarkable.
.
GASTROINTESTINAL: The appendix is unremarkable. There is no intestinal
obstruction or ascites. Calcified nodules in the sigmoid mesocolon are likely
sequela of prior epiploic appendagitis.
PELVIS: There is no free fluid in the pelvis.There is endometrial thickening
versus fluid within the endometrial cavity. A simple appearing right adnexal
cyst measures 5 cm. The left ovary is unremarkable for age..
LYMPH NODES: No enlarged abdominal or pelvic lymph nodes.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: Compression fracture of L1 is noted. Please refer to the recent MRI of
the spine.
SOFT TISSUES: Rectus diastasis. Injection granulomas are seen in the gluteal
regions.
IMPRESSION:
1. No findings of primary malignancy or metastatic disease in the abdomen or
pelvis.
2. Incidental findings such as 5 cm simple appearing right adnexal cyst and
endometrial thickening versus fluid in the endometrial cavity. Consider
pelvic ultrasound.
3. Redemonstration of thoracolumbar compression fractures, better assessed
on recent MRI of the spine.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with multiple vertebral body compression
fractures. Evaluate for fractures and malignancy.
TECHNIQUE: Multi detector axial CT images were obtained through the chest
after the uneventful administration of 130 cc of Omnipaque 350 intravenous
contrast as part of a CT torso. Coronal, sagittal, axial thin slice and axial
maximum intensity projection images were produced and reviewed on PACs.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 64.1 cm; CTDIvol = 17.7 mGy (Body) DLP =
1,132.3 mGy-cm.
2) Stationary Acquisition 6.1 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP =
16.8 mGy-cm.
Total DLP (Body) = 1,149 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: MR total spine of ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Nonenlarged supraclavicular lymph
nodes measure up to 5 mm (302:32). Axillary lymph nodes are not enlarged. 10
mm nodule in the left breast is incompletely evaluated (302:110).
UPPER ABDOMEN: Please see the separately dictated CT abdomen and pelvis report
from the same date for description of subdiaphragmatic findings.
MEDIASTINUM: There is mediastinal lymphadenopathy measuring up to 15 mm in the
right low paratracheal station (302:76).
HILA: A right hilar lymph node measures 11 mm (302:99) no enlarged left hilar
lymph nodes.
HEART and PERICARDIUM: Heart size is normal. Coronary artery calcifications
are moderate and diffuse.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: Respiratory motion moderately limits evaluation for fine
detail. The background of ground-glass opacity is probably mild pulmonary
edema. A right upper lobe spiculated nodule measures 8 x 9 mm (302:53). The
nodule abuts but does not appear to extend into the pleura. There is also a 6
mm left upper lobe nodule (302:86).
2. AIRWAYS: Airways are patent to the subsegmental level bilaterally.
3. VESSELS: The main, right and left pulmonary arteries are normal in
caliber. While this study is not optimized for the evaluation of pulmonary
vasculature, no central pulmonary embolism is detected. The thoracic aorta is
normal in caliber with moderate calcified atherosclerotic plaque.
CHEST CAGE: Compression fracture of the T7 vertebral body with 50% height loss
and no significant retropulsion is more completely assessed on MRI of the
thoracic spine of ___. No additional fractures or suspicious
lytic or sclerotic osseous lesions are detected.
IMPRESSION:
9 mm right upper lobe nodule is suspicious for malignancy given the presence
of right hilar and mediastinal lymphadenopathy. Options for follow-up include
an FDG PET-CT now or repeat chest CT in 3 months.
Attention should also be paid to a 6 mm left upper lobe nodule on follow-up
imaging.
Mild pulmonary edema.
Compression fracture of the T7 vertebral body with 50% height loss is more
completely assessed on thoracic spine MRI of ___. No additional
fractures in the thoracic spine or rib cage.
10 mm left breast nodule is incompletely evaluated on this study. Recommend
mammography if it has not been recently performed.
Please see the separately dictated CT abdomen and pelvis report from the same
date for description of subdiaphragmatic findings.
RECOMMENDATION(S): FDG PET-CT now or chest CT in 3 months for continued
assessment of 9 mm right upper lobe pulmonary nodule.
Mammography if it has not been recently performed.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with thoracic and lumbar compression fractures
found to have right adnexal cyst and endometrial thickening versus fluid in
the endometrial cavity on CT// evaluate adnexal cyst and endometrial
thickening vs fluid
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
The uterus is anteverted and measures 3.9 x 1.9 x 4.0 cm cm. The endometrium
is homogenous and measures 2 mm. Simple appearing fluid is seen in the
endometrial cavity.
The ovaries are not visualized. A simple appearing right adnexal cystic
lesion measures 5.4 x 4.4 x 4.5 cm. There is no free fluid in the pelvis.
IMPRESSION:
1. Simple appearing fluid in the endometrium suggesting cervical stenosis. No
endometrial thickening.
2. 5.4 cm simple appearing right adnexal cystic lesion.
RECOMMENDATION(S): Follow-up pelvic ultrasound in ___ year to assess right
adnexal cystic lesion.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Lower back pain
Diagnosed with Low back pain
temperature: 97.4
heartrate: 94.0
resprate: 18.0
o2sat: 97.0
sbp: 120.0
dbp: 96.0
level of pain: 8
level of acuity: 2.0 | ___ female with a history of compression fracture in
___ presented with nontraumatic worsening lower back
pain found to have compression fractures of L1 and T7, and
possible malignant masses on CT torso.
# L1 acute compression fracture:
# T7 subacute compression fracture:
Patient with known T7 compression fracture from earlier this
year presenting with a nontraumatic L1 compression fracture.
Given the lack of trauma there was concern for a pathologic
fracture due to either malignancy or osteoporosis. CT torso was
pursued which showed small nodules of the right upper lobe, left
upper lobe and left breast along with mediastinal
lymphadenopathy together concerning for malignancy.
Interventional pulmonology was consulted who recommended PET CT
first. Notably vitamin D levels were low, patient was possibly
on vitamin D and calcium supplementation in ___ though
she denies imaging/DEXA scans in the past. She was fitted with
TLSO brace with marked improvement in pain after ___ evaluation
and treatment. No focal neurologic deficits developed during the
hospital course. Follow-up was arranged with PCP to organize
PET/CT as well as DEXA scan for workup of possible pathologic
fracture.
# Concern for malignancy:
As noted above hilar adenopathy, lung lesions and breast lesions
were noted. Otherwise no endometrial thickening, labs were not
suggestive of malignancy. Patient denied weight loss. Follow-up
was arranged with PCP to continue the workup.
# Hypertension:
Patient is a history of hypertension and she was continued on
her home medications without marked periods of hypertension or
hypotension.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
Right ankle pain
Major Surgical or Invasive Procedure:
Status post right ankle I&D/open reduction internal fixation
___, ___
History of Present Illness:
___ female with Diabetes, CHF, COPD, CAD status post CABG (per
the
patient's daughter), GERD, gout, fibromyalgia, CKD who presents
with right ankle fracture dislocation. There are 2 transverse
lacerations approximately 5 cm above the medial malleolus. It
is
difficult on exam to tell if these probes deeply and communicate
with the fracture. She was given Ancef in the ED and tetanus
was
confirmed. She underwent closed reduction with propofol
sedation. this injury will require surgical fixation.
Past Medical History:
Diabetes, high cholesterol, morbid obese, smoker, kidney
disease, stents on the leg, stroke, heart attack, asthma,
arthritis, gout, thyroid problems.
Social History:
___
Family History:
n/c
Physical Exam:
General: Well-appearing female in no acute distress.
Right lower extremity:
-There are 2 horizontal lacerations approximately 5 cm proximal
to the medial malleolus. More proximal laceration is
approximately 4 cm in length. More distal laceration is
approximately 2 cm. There is scattered ecchymosis
- Fires weak ___
- SILT S/S/SP/DP/T distributions though she does have decreased
sensation in her great toe
- 2+ palpable DP, 2+ ___ pulse by Doppler, WWP
Medications on Admission:
Gabapentin 300 mg nightly
Allopurinol ___ mg PO DAILY
Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN dry
eyes
Atorvastatin 40 mg PO QPM
Furosemide 80 mg PO DAILY
Insulin SC Sliding Scale
Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN wheezing
Levothyroxine Sodium 175 mcg PO DAILY
Losartan Potassium 25 mg PO DAILY
Omeprazole 20 mg PO DAILY
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H:PRN wheezing
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Cephalexin 500 mg PO Q6H Duration: 14 Days
3. Cyclobenzaprine 5 mg PO TID:PRN Muscle spasms
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth q8 PRN Disp #*40
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously at bedtime Disp
#*30 Syringe Refills:*0
6. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*40 Capsule Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q4 PRN Disp #*40
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Allopurinol ___ mg PO DAILY
11. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN
dry eyes
12. Atorvastatin 40 mg PO QPM
13. Furosemide 80 mg PO DAILY
14. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
15. Ipratropium-Albuterol Neb 1 NEB NEB TID:PRN wheezing
16. Levothyroxine Sodium 175 mcg PO DAILY
17. Losartan Potassium 25 mg PO DAILY
18. Omeprazole 20 mg PO DAILY
19. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H:PRN
wheezing
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right open ankle fracture
Discharge Condition:
AVSS
NAD, A&Ox3
RLE: Foot resting in short leg splint that is clean, dry, and
intact. Fires exposed toes, sensation intact light touch and
exposed toes, warm and well-perfused exposed
Foley catheter in place
Followup Instructions:
___
Radiology Report
EXAMINATION: Right ankle radiographs, three views.
INDICATION: Right ankle fracture status post reduction.
COMPARISON: Earlier on the same day.
FINDINGS:
Right ankle has been reduced. Fractures again involve the distal fibula, the
medial malleolus, and the anterior lip of the distal tibia. These fractures
all show small residual displacements. Medial ankle mortise is mildly
widened. Bony detail is partly obscured by overlying splinting material.
IMPRESSION:
Status post reduction.
Radiology Report
EXAMINATION: Q61R
INDICATION: ___ year old woman with right ankle fracture// eval tight ankle
fracture CT mid shin to foot.
TECHNIQUE: ___ MD CT imaging was performed through the right lower
extremity from the mid calf to the toes. Coronal and sagittal reformats were
produced and reviewed. Additional reformats were performed on PACS for
further evaluation.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 46.9 cm; CTDIvol = 11.8 mGy (Body) DLP = 554.6
mGy-cm.
Total DLP (Body) = 555 mGy-cm.
COMPARISON: Right ankle radiographs ___
FINDINGS:
There is a trimalleolar right ankle fracture with a transverse fracture
through the medial malleolus (10:2), minimally displaced posterior malleolus
fracture (401:46) and a comminuted oblique fracture through the distal fibular
diaphysis above the level of the syndesmosis (10:3). The ankle mortise is
congruent on these nonstress views. There is an additional fracture along the
anterolateral aspect of the tibial plafond and (10:4) at the expected site of
attachment of the anterior tibiofibular ligament, highly suspicious for
disruption of this ligament. Multiple small calcifications are seen in the
expected location of the posterior talofibular ligament (2:112) as well as in
the deltoid ligament (2:110) likely reflecting remote injuries.
Evaluation of the soft tissue structures around the ankle is limited, no
definite tendon entrapment seen. There is diffuse soft tissue swelling around
the ankle but no definite tibiotalar joint effusion.
There is a multipartite os navicularis a likely reflecting chronic
enthesopathic changes at the posterior tibialis insertion (2: 119). Moderate
vascular calcification.
No additional fracture seen.
IMPRESSION:
1. Trimalleolar ankle fracture, minimally displaced although imaging is
performed in a cast.
2. Small bony fragments along the anterolateral aspect of the tibial plafond
and highly suspicious for disruption of the anterior tibiofibular ligament.
3. Evidence of remote sprains of the posterior tibiofibular and deltoid
ligaments.
4. Diffuse soft tissue swelling.
5. Extensive vascular calcification.
Radiology Report
EXAMINATION: ANKLE (AP, LAT AND OBLIQUE) IN O.R. RIGHT
INDICATION: ANKLE (AP, LAT AND OBLIQUE) IN O.R. RIGHT, fluoroscopic guidance
for intraoperative internal fixation
TECHNIQUE: ANKLE (AP, LAT AND OBLIQUE) IN O.R. RIGHT
COMPARISON: ___
FINDINGS:
6 intraoperative images were acquired without a radiologist present.
Images show shows evidence of internal fixation of the tibia and fibula
fracture.
IMPRESSION:
Intraoperative images were obtained during internal fixation of the tibial and
fibular fractures. Please refer to the operative note for details of the
procedure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF and hypotension// Rule out flash
pulmonary edema
IMPRESSION:
No previous images. There are low lung volumes that accentuate the prominence
of the transverse diameter of the heart. Relatively mild pulmonary vascular
congestion.
No evidence of acute focal consolidation. Intact midline sternal wires
following apparent CABG procedure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ DM2, CHF (2 pillow orthopnea, Lasix at home), CAD (s/p CABG
in ___, CKD (baseline 1.6), fibromyalgia, GERD, Gout p/w open right ankle
fracture s/p I D and open reduction internal fixation of anklefracture and
subsequently closed reduction with propofol sedation. Was getting discharged
today. Noted to have elevation in Cr and hypotension to SBP ___. Concern for
sepsis. There was a concern for new onset Afib but EKG does not appear to be
Afib.// evaluate interval change
IMPRESSION:
In comparison with the study ___, there are slightly improved lung
volumes. Continued substantial enlargement of the cardiac silhouette with
some increase in engorgement of indistinct pulmonary vessels consistent with
elevated pulmonary venous pressure. The left hemidiaphragmatic contour is no
longer seen, suggesting a combination of pleural fluid and volume loss in the
left lower.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Oth fx upper and low end r fibula, init for opn fx type I/2, Fall same lev from slip/trip w/o strike against object, init
temperature: 98.1
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 164.0
dbp: 86.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right open ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for I&D as well as open reduction
internal fixation of right ankle, which the patient tolerated
well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ anticoagulation per
routine. While inpatient, the patient was continued on IV Ancef
for prophylaxis against surgical site infection. This was
converted to p.o. Keflex at discharge.
Pain control was somewhat of an issue during this
hospitalization. The patient reported poor pain control and on
___ her narcotic pain regimen was increased slightly. At this
time the patient had a spell where she stared blankly forward
for roughly 1 minute as witnessed by her family members. Her
family was concerned about a possible seizure and neurology was
consulted. Neurology was not concerned for a seizure and
recommended no further workup. They suggested the patient
follow-up in neurology clinic as desired. The pain service also
saw the patient after this event and suggested achieving pain
control through gabapentin and Flexeril in addition to Tylenol
and, if needed, oxycodone used sparingly. With this regimen,
her pain was well controlled.
The patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact. She did
have some difficulty with urination postoperatively. She was
straight cathed multiple times and ultimately a Foley was
placed. A trial of removal of this Foley should occur in ___
days. The patient is NWB in the right extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Catheterization with drug eluting stent placement
History of Present Illness:
Mr. ___ is an ___ year old man with a PMHx s/f CAD, lung
cancer, and prostate cancer who presented to his PCP's office
with 2 months of worsening angina and shortness of breath. He
states that for the last 2 months he has had worsening
exertional non-pleuritic chest tightness. The pain worsens with
activity, and improves with rest. It has been worsening in its
duration, whereas previously the pain would improve in several
minutes, over the last several days the pain has taken several
hours to improve. He has not used nitroglycerin for the pain.
.
Mr. ___ also notes anorexia and dramatic weight loss of 60
lbs. over 60 days. Upon review of his flowsheets however, he has
only lost 6 lbs over 60 days. He also espouses occassional
"shaking in the face", as well as constipation. ROS is also
positive for dysuria.
.
In the ED, initial VS were 96.7 47 142/67 16 99% RA. CXR was
significant for left upper lung linear opacity and worsening of
RLL opacity. Troponins were negative x 1. He was given
levofloxacin, and 1L NS.
.
ROS: per HPI, denies fever, chills, night sweats, rhinorrhea,
congestion, sore throat, cough, abdominal pain, nausea,
vomiting, diarrhea, BRBPR, melena, hematochezia, hematuria.
Past Medical History:
1. Lung cancer - The patient is followed by Dr. ___ at the
___. He was treated on a study
protocol
and is now considered to be in remission. However, he may have
a recurrence of his malignancy given his current symtpoms.
2. Weight loss - The patient has lost a significant amount of
weight since his last clinic visit.
3. Lower extremity pain - Now resolved with daily streching
exercises.
4. Type 2 diabetes mellitus - The patient's finger sticks have
been running quite high. He will follow up with Dr. ___ in
the
next couple of weeks.
5. Depression - The patient feels that he is doing well in
respect to his depression at this time.
6. Decreased hearing
7. Cataracts
8. Prostate cancer status post prostatectomy - followed by Dr.
___
9. Memory concerns
10. Urinary incontinence
11. Falls
12. Gait instability
13. Diplopia
14. Groin infection - ___
15. Full-thickness rotator cuff tear of his right shoulder
PAST SURGICAL HISTORY:
1. Status post prostatectomy
2. Status post artificial urinary sphincter implantation
3. Status post cholecystectomy
Social History:
___
Family History:
Father with CAD and brain cancer, mother with AD
Physical Exam:
Upon Admission:
VS - Temp ___ F, 116/51 BP , 49 HR , 18 R , 99 O2-sat % RA
GENERAL - cachectic man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
VS - 98.6 104/49-135/45 ___ 18 98%RA
GENERAL - cachectic man in NAD, comfortable, appropriate
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
ADMISSION LABS
___ 10:40AM BLOOD WBC-5.6 RBC-4.23* Hgb-12.7* Hct-38.6*
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 Plt ___
___ 10:40AM BLOOD Neuts-78.2* Lymphs-16.4* Monos-3.7
Eos-1.3 Baso-0.3
___ 04:10PM BLOOD ___ PTT-82.6* ___
___ 10:40AM BLOOD Glucose-124* UreaN-23* Creat-1.1 Na-142
K-4.9 Cl-108 HCO3-29 AnGap-10
___ 10:40AM BLOOD Calcium-10.1 Phos-3.5 Mg-2.3
.
DISCHARGE LABS
___ 06:50AM BLOOD WBC-6.2 RBC-3.70* Hgb-10.8* Hct-34.0*
MCV-92 MCH-29.3 MCHC-31.9 RDW-13.7 Plt ___
___ 06:40AM BLOOD Neuts-77.5* Lymphs-15.5* Monos-4.3
Eos-2.6 Baso-0.1
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-90 UreaN-18 Creat-1.1 Na-143
K-4.3 Cl-110* HCO3-29 AnGap-8
___ 12:50PM BLOOD CK(CPK)-28*
___ 12:50PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:40AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0 Cholest-95
___ 06:40AM BLOOD Triglyc-124 HDL-38 CHOL/HD-2.5 LDLcalc-32
.
CARDIAC ENZYMES
___ 10:40AM BLOOD CK-MB-2
___ 10:40AM BLOOD cTropnT-<0.01
___ 05:17PM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:47PM BLOOD CK-MB-2
___ 06:40AM BLOOD CK-MB-2
___ 12:50PM BLOOD CK-MB-2 cTropnT-<0.01
.
PERTINENT LABS
___ 08:45AM BLOOD HIV Ab-NEGATIVE
___ 08:45AM BLOOD Lithium-0.9
___ 10:40AM BLOOD Lactate-1.1
___ 08:45AM BLOOD Lipase-35
___ 08:45AM BLOOD Amylase-102*
.
PERTINENT STUDIES
Chest X ray: ___
IMPRESSION:
1. Left upper lung linear opacity may represent
lingering/residual pneumonia or an area of bronchiectatic
inflammation - reimaging after treatment may be considered.
2. Increase in right lower lung nodule size; reimaging with
nipple markers may be considered.
.
Stress Test: ___
IMPRESSION: Anginal type symptoms with ischemic ECG changes at a
fair functional capacity. Nuclear report sent separately.
.
Nuclear Perfusion Scan: ___
IMPRESSION: Normal myocardial perfusion study. Normal left
ventricular size and function. Previously noted reversible
defect has improved.
.
Cath: ___
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated three vessel coronary artery disease. The ___ had
no
angiographically significant coronary artery disease. The LAD
had an 80%
in-stent restenosis within the mid LAD, and a 50% stenosis in
the distal
LAD. The very distal LCX had an 80% stenosis. The RCA was small
calibur
and diffusely diseased with a 90% ostial stenosis and an 80%
proximal
stenosis.
2. Limited resting hemodynamics revealed mild systemic arterial
hypertension with a central aortic blood pressure of 142/51.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. In-stent restenosis of the mid LAD
3. Mild systemic arterial hypertension.
.
TTE ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). The aortic valve is not well
seen. There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. The mitral valve leaflets are not
well seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Medications on Admission:
aspirin 325 mg daily,
Plavix 75 mg daily
metoprolol succinate 25 mg daily,
isosorbide mononitrate 30 mg daily,
pravastatin 40 mg daily,
lithium 300 mg daily,
omeprazole 40 mg daily,
calcium 600-400 BID
Ferrous Sulfate 325mg daily
Cyanocobalamin 1000 mcg daily
loratidine 10mg daily
multivitamin daily
Senna/Colace
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
8. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
14. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO QID (4 times a day) as needed for heartburn.
15. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Coronary Artery Disease
Depression
Prior Lung Cancer, in remission
Prior Prostate Cancer s/p prostectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with chest tightness.
STUDY: Portable AP upright chest radiograph.
COMPARISON: ___.
FINDINGS: The cardiomediastinal and hilar contours are normal. The lungs
show an area of linear density in the left upper lung which correlates to an
area of consolidation on ___ CT. The nodular density projecting over the
left hemidiaphragm likely represents a nipple shadow and was seen on prior
exam; the nodular density over the right hemidiaphragm correlates to a nodule
seen on ___ CT and has increased in size. There is no pleural effusion or
pneumothorax.
IMPRESSION:
1. Left upper lung linear opacity may represent lingering/residual pneumonia
or an area of bronchiectatic inflammation - reimaging after treatment may be
considered.
2. Increase in right lower lung nodule size; reimaging with nipple markers may
be considered.
Findings were posted to the Critical Results Dashboard at 15:11 on ___ by
___
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST TIGHTNESS
Diagnosed with CHEST PAIN NOS, WEIGHT LOSS, ABNORMAL, PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, DIABETES UNCOMPL ADULT, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 96.7
heartrate: 47.0
resprate: 16.0
o2sat: 99.0
sbp: 142.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ year old man with a past medical history
significant for CAD, lung cancer, and prostate cancer who
presented to his PCP's office with unstable angina.
.
ACTIVE ISSUES
# Unstable Angina: Initially there was concern for unstable
angina versus NSTEMI given 1 week of chest pain. There were no
EKG changes concerning for STEMI, and no troponin elevations so
unstable angina was diagnosed. Although levofloxacin was given
in the ED, in the floor we doubted pneumonia given lack of
clinical findings concerning for pneumonia (no cough, sputum
production, fever, pleuritic chest pain) and CXR findings are
not very impressive; LUL infiltrates may correspond to prior
area of radiation. Positive stress test on ___ by EKG, but
no areas of ischemia on nuclear imaging possibly consistent with
balanced ischemia. Cardiac cath was performed on ___ which
demonstrated restenosis in the BMS in the proximal LAD. A DES
was placed in the mid LAD. The post-procedure course was
notable for significant improvement of his chest pressure. He
continued to complained of intermittent atypical chest pains not
accompanied by EKG changes or cardiac enzyme elevations and
relieved by maalox. Pt was seen by ___, who recommended rehab.
.
# Thrombocytopenia: Given quick onset < 48 hours after
initiation of heparin, likely HIT type I (benign non-antibody
mediated, self-resolving) vs. volume mediated. Upon discharge
platelet count was 133.
.
CHRONIC ISSUES
# Depression/Bipolar: Lithium was continued.
.
# Failure to thrive/Anorexia: Differential included worsening
depression, malignancy, CAD, and indolent infection. Doubt
malignancy given that Mr. ___ was recently deemed to be in
total remission per Dr. ___. Pt was HIV negative. Nutrition
consult recommended encouragement of Glucerna shakes.
.
TRANSITIONAL ISSUES
# CODE STATUS: DNR/DNI
# MEDICATION CHANGES: none
# FOLLOW UP PLAN:
- Gerontology appt on ___
- Cardiology appt with Dr. ___ on ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Valium / Biaxin / Levaquin / Ace Inhibitors / Bactrim /
Ciprofloxacin / Vicodin ES / metoprolol / Dilaudid / Macrobid /
tramadol / Zetia
Attending: ___
___ Complaint:
sore throat
Major Surgical or Invasive Procedure:
Bedside ENT scope ___
History of Present Illness:
Ms. ___ is a ___ woman with a history of hypertension,
paroxysmal atrial fibrillation (on home anticoagulation),
pacemaker for tachybrady syndrome, and peripheral vascular
disease, who is presenting with fever and sore throat for three
days. Patient first noted an "ache" in her mouth and right side
of her neck 3 days ago. She was also having subjective fevers
and difficulty swallowing. No difficulty breathing. She first
presented to her doctor yesterday, who prescribed her an unknown
antibiotic. However, she developed increased neck swelling
overnight, and so presented to the ED.
In the ED, initial vitals: 100.2 97 ___ 98% RA
- Exam notable for submental edema and tenderness with
induration.
- Labs were notable for a white count of 16.9, normal lactate,
Cr 1.1, INR 1.4.
- A CT neck w/ contrast was done, which showed sialadenitis
involving the right ___ duct and submandibular gland with
reactive lymphadenopathy and substantial adjacent inflammation
extending into the right sublingual space, parapharyngeal space,
and carotid space without an organized fluid collection
identified. Inflammatory change extending into the right
sublingual space raises the possibility of Ludwig's angina.
- Patient was given unasyn 3g, dexamethasone 10mg, and 1L NS
- ENT was consulted, and did a bedside scope showing some mild
airway edema.
Patient was admitted to the ICU for airway monitoring.
On arrival to the MICU, patient feeling much improved and would
like to try eating something soft.
Past Medical History:
- HTN
- Autonomic dysfunction
- Overweight
- Sleep apnea
- Anemia
- CRI on HCTZ, now improved off HCTZ
- Post-herpetic neuralgia treated with gabapentin
- PVD with right toe amputations ___
- Atrial fibrillation
- GERD
- Osteoporosis
- Admitted ___ to ___ for fever ? due to virus
- L4 compression fracture ___ from dizziness (HCTZ induced)
and fall
- Palpitations. Resolved on atenolol, which has now been
stopped due to fatigue; infrequent palpitations now.
- Low vitamin D level. Continue vitamin D ___ IU daily.
- Elevated alkaline phosphatase thought due to vertebral
fracture.
- Adhesive capsulitis secondary to seat belt syndrome
PSH:
- ___ amputations of right toes 2,3 & 4 and left great toe
- Left fem-pop bypass and first toe amp on ___
- ___ - right SFA to BK popliteal bypass with PTFE
- ___ common femoral artery endarterectomy with vein patch
angioplasty
- Total abdominal hysterectomy/BSO ___
- s/p appendectomy
- s/p tonsillectomy and adenectomy
Social History:
___
Family History:
mother - hypertension
father - pancreatic cancer
brother - CAD
Physical ___:
ADMISSION EXAM:
Vitals: reviewed in metavision
Gen: Patient speaking in full sentences
HEENT: Significant LAD on right side of neck, nonpainful to
palpation. Mouth with swelling of right side of tongue. Able to
express purulent materal from ___ duct.
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, systolic ejection murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no edema. Left and right toe amputations
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
===============
ADMISSION LABS
===============
___ 10:04AM BLOOD WBC-16.9*# RBC-4.19 Hgb-10.4* Hct-34.1
MCV-81* MCH-24.8* MCHC-30.5* RDW-14.9 RDWSD-43.8 Plt ___
___ 10:04AM BLOOD Neuts-83.9* Lymphs-5.9* Monos-9.0
Eos-0.1* Baso-0.3 Im ___ AbsNeut-14.14*# AbsLymp-1.00*
AbsMono-1.51* AbsEos-0.01* AbsBaso-0.05
___ 10:04AM BLOOD Plt ___
___ 10:04AM BLOOD Glucose-108* UreaN-19 Creat-1.1 Na-137
K-4.1 Cl-100 HCO3-21* AnGap-20
___ 05:02AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
___ 10:12AM BLOOD Lactate-1.0
============
MICROBIOLOGY
============
___ 6:15 pm ABSCESS Source: Oral abscess.
Fluid should not be sent in swab transport media. Submit
fluids in a
capped syringe (no needle), red top tube, or sterile cup.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
===============
IMAGING
===============
CT Neck w/ Contrast ___: 1. Sialadenitis involving the right
___ duct and submandibular gland
with reactive lymphadenopathy and substantial adjacent
inflammation extending
into the right sublingual space, parapharyngeal space (including
right
infratemporal fossa), and carotid space without an organized
fluid collection
identified. Inflammatory change extending into the right
sublingual space
raises the possibility of Ludwig's angina. No definite
involvement of the
retropharyngeal space.
2. No definite enhancing confluent fluid collection.
CXR ___: Right sided PICC tip in the mid SVC. No pneumothorax.
===============
DISCHARGE LABS
===============
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Diltiazem Extended-Release 180 mg PO DAILY
2. Ketoconazole 2% 1 Appl TP DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY
___ MD to order daily dose PO DAILY16
6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
7. Vitamin D ___ UNIT PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*12 Tablet Refills:*0
2. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily as
instructed Disp #*18 Tablet Refills:*0
3. Warfarin 3 mg PO DAILY16
4. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
5. Diltiazem Extended-Release 180 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ketoconazole 2% 1 Appl TP DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Rosuvastatin Calcium 5 mg PO EVERY OTHER DAY
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Sialadenitis and sialolith
Secondary Diagnosis:
- Atrial Fibrillation
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ with sore throat, febrile, and difficulty tolerating
secretions.
TECHNIQUE: Imaging was performed after administration of 70 ml of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.1 s, 31.9 cm; CTDIvol = 12.7 mGy (Body) DLP = 405.2
mGy-cm.
2) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 4.4 mGy (Body) DLP = 8.8
mGy-cm.
3) Sequenced Acquisition 0.5 s, 2.0 cm; CTDIvol = 4.4 mGy (Body) DLP = 8.8
mGy-cm.
Total DLP (Body) = 423 mGy-cm.
COMPARISON: ___ cervical spine CT, ___ noncontrast neck
CT
FINDINGS:
Dental amalgam artifact limits evaluation at the level of dentition.
There are calcifications within the right ___ duct measuring 4 and 5 mm
(02:46) with proximal dilatation of ___ duct up to 7 mm (02:45). There
is substantial adjacent fat stranding extending into the right sublingual
space, parapharyngeal space (including right infratemporal fossa), and
carotid space with mass effect on the ipsilateral aerodigestive tract. There
is a small amount of fluid in the piriform sinuses with effacement of the
right piriform sinus, but the aerodigestive tract is otherwise patent. There
is no definite extension of inflammatory change into the retropharyngeal
space. There is asymmetric heterogeneous enhancement of the ipsilateral
submandibular gland. The remaining salivary glands enhance normally and are
without mass or adjacent fat stranding.
A right level 1B lymph node measures 1.1 cm (02:51), a right level IIa lymph
node measures 1.2 cm (02:45), and a right level 4 lymph node measures 1.8 cm
(02:57), likely reactive.
The thyroid gland appears normal. The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions. Limited evaluation the
paranasal sinuses reveals partial opacification of the right sphenoid sinus
and ethmoid air cells.
IMPRESSION:
1. Sialadenitis involving the right ___ duct and submandibular gland
with reactive lymphadenopathy and substantial adjacent inflammation extending
into the right sublingual space, parapharyngeal space (including right
infratemporal fossa), and carotid space without an organized fluid collection
identified. Inflammatory change extending into the right sublingual space
raises the possibility of Ludwig's angina. No definite involvement of the
retropharyngeal space.
2. No definite enhancing confluent fluid collection.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with PICC placement.
TECHNIQUE: Portable AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
A right-sided PICC tip terminates in the mid SVC. No pneumothorax. Left-sided
pacer device is noted with leads terminating in the right atrium and right
ventricle. Mild cardiomegaly is re- demonstrated. The aorta is diffusely
calcified. The mediastinal and hilar contours are unchanged. Pulmonary
vasculature is not engorged. Streaky opacities in the lung bases likely
reflect areas of atelectasis. No pleural effusion or pneumothorax is present.
Osseous structures are diffusely demineralized.
IMPRESSION:
Right sided PICC tip in the mid SVC. No pneumothorax.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Sore throat, ILI
Diagnosed with Sialoadenitis, unspecified
temperature: 100.2
heartrate: 97.0
resprate: 20.0
o2sat: 98.0
sbp: 201.0
dbp: 93.0
level of pain: 5
level of acuity: 3.0 | SUMMARY: Ms. ___ is a ___ woman with a history of
hypertension, paroxysmal atrial fibrillation (on home
anticoagulation), pacemaker for tachybrady syndrome, and
peripheral vascular disease, who is presenting with fever and
sore throat for three days, now in the ICU for airway monitoring
given concern for Ludwig's angina.
# Submandibular swelling: Patient presented with right
submandibular gland sialadenitis with 2 stones in Wharthin's
duct. There was initial concern for Ludwig's Angina. ENT was
consulted and evaluated the patient. Bedside scope was performed
which showed airway edema. She was given dexamethasone 10mg,
started on unasyn (d1 = ___. Per ENT recs she was given warm
compresses, firm salivary gland massage, and sialogogues. Her
swelling quickly improved. She improved and was discharged home
with a 10-day course of augmentin.
# Leukocytosis: Patient presented with a WBC of 16. Most likely
related to siladenitis as above. Patient had no other localizing
symptoms and other studies were not concerning for UTI or PNA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hip pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of right intertrochanteric
femur fracture with TFN- ___
History of Present Illness:
___ otherwise fairly healthy presenting after fall onto right
side today. She was walking her dog when there was a sharp tug
on
the leash causing her to lose her balance and land on the right
side. Immediate onset of pain and inability to bear weight. No
numbness, tingling, no head strike. The patient denies LOC,
premonitory symptoms and ROS is otherwise at baseline.
Past Medical History:
HTN
Benign breast biopsy
lichen sclerosus
osteoporosis
basal cell cancer
retinal
detachment
L1 vertebral fractures status post MVA in ___
Palpitations
Social History:
She is a nonsmoker. Does not drink alcohol or
abuse drugs. She works as a ___. She is in a
long-term relationship. She has 2 daughters.
Physical Exam:
Exam on Admission:
AVSS, AA0x3
Boarded and collared, moving all extremities, responding
appropriately
MSK:
RUE - No pain with ROM of the shoulder, elbow, or wrist, NVI.
LUE - No pain with ROM of the shoulder or elbow, some pain with
ROM of the wrist and digits, TTP about the wrist.
RLE - Significant swelling of the ankle, skin intact. TTP. No
obvious deformity, NVI. No pain with ROM of the hip or knee.
LLE - No pain with ROM of the hip, knee, or ankle.
Exam on Discharge:
AVSS
NAD
RLE: Incision with staples intact, no erythema or drainage
Firing ___, FHL, TA, ___
Sensation intact SP, DP, Sa, ___, T
Warm and well-perfused
Pertinent Results:
___ 07:20AM BLOOD WBC-6.8 RBC-2.78* Hgb-8.6* Hct-25.5*
MCV-92 MCH-30.9 MCHC-33.6 RDW-13.1 Plt ___
Medications on Admission:
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1250 mg PO TID
4. Diazepam 5 mg PO Q6H:PRN muscle spasm
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID Duration: 14 Days
7. Metoprolol Succinate XL 25 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*80 Tablet Refills:*0
9. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R.
INDICATION: ORIF.
TECHNIQUE: Several intraoperative fluoroscopic spot images were acquired of
the right hip, without a radiologist present.
COMPARISON: Hip radiographs from ___.
FINDINGS:
Intraoperative fluoroscopic spot images of the right hip demonstrate ORIF of a
comminuted intertrochanteric fracture. There is no evidence of hardware
complication. For additional details, please see the operative report in the
___ medical record.
The total fluoroscopic time was 52.6 seconds.
IMPRESSION:
As above.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with INTERTROCHANTERIC FX-CL, OTHER FALL, ACTIVITIES INVOLVING WALKING AN ANIMAL, HYPERTENSION NOS
temperature: 98.5
heartrate: 74.0
resprate: 18.0
o2sat: 99.0
sbp: 137.0
dbp: 68.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ presented to the ___ emergency department on
___ and was evaluated by the orthopedic surgery team. The
patient was found to have right intertrochanteric femur fracture
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for ORIF right hip
fracture with TFN, which the patient tolerated well (for full
details please see the separately dictated operative report).
The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight-bearing as tolerated in the
right lower extremity, and will be discharged on subcutaneous
heparin for DVT prophylaxis. The patient will follow up in two
weeks per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course, and all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin / morphine / Percocet
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ F w/ hx of COPD, DM and hypothyroidism who
presents with 1 day of dyspnea and hemoptysis.
Patient reported having blood tinged sputum with increasing
amounts of blood since yesterday (___). No prior hemoptysis or
ongoing cough. She also had fatigue and decreased appetite for
the past 2 weeks. Patient denied chest pain or palpitations. She
denied any lower extremity pain or swelling, history of blood
clots, recent travel, recent surgeries, incarceration.
Approximately 3 weeks ago, patient had a complicated nosebleed
s/p surgery at ___. There was no prior episode of epistaxis, and
it has not recurred. One week later, she was admitted to ___ from ___ for weakness, found to have anemia (hct
23.9 from baseline of 36) and CT chest notable for
bronchiectasis
and diffuse lymphadenopathy.
Past Medical History:
DM
COPD
Hypothyroidism
History of tobacco use
Social History:
___
Family History:
DM, aplastic anemia, CAD. No family history of lupus,
vasculitis,
RA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: Temp 98.6, BP 148/69, HR 98, RR 18, O2 sat 94 on 3L NC.
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, ___ to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. ___ intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
======================
24 HR Data (last updated ___ @ 519)
Temp: 98.1 (Tm 98.3), BP: 157/74 (___), HR: 79
(___), RR: 18, O2 sat: 94% (___), O2 delivery: Ra (2L NC -3
LNC), Wt: 176.37 lb/80 kg
GENERAL: Pleasant woman, comfortable breathing on RA,
sitting up in chair, speaking in full sentences without breaks
or coughs
HEENT: Anicteric, EOMI, MMM without OP lesions
CARDIAC: RRR.
LUNG: Breathing comfortably, in no respiratory distress, mild
wheezing diffusely in posterior lung fields with improved breath
sounds, no cough; air movement throughout
ABD: Soft, ___, positive bowel sounds
EXT: Warm, well perfused, no lower extremity edema/swelling.
NEURO: A&Ox3, no focal neurological deficits, linear thought
SKIN: No significant rashes.
Pertinent Results:
INITIAL RESULTS:
=============
___ 02:30PM URINE ___
___ 02:30PM URINE ___
___ 02:30PM URINE ___
___
___ 02:30PM URINE ___
___
___
___ 02:30PM URINE ___ SP ___
___ 02:30PM URINE ___
___ 02:30PM URINE ___
___ 02:40PM RET ___ ABS ___
___ 02:40PM ___
___ 02:40PM PLT ___ PLT ___
___ 02:40PM ___ ___
___ 02:40PM ___
___ REVI
___ 02:40PM ___
___ IM ___
___
___ 02:40PM ___
___
___ 02:40PM ___
___ 02:40PM cTropnT-<0.01 ___
___ 02:40PM LD(LDH)-252* TOT ___ DIR BILI-<0.2 INDIR
___
___ 02:40PM ___ this
___ 02:40PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 02:43PM ___
___ 02:43PM ___ TOTAL
___ BASE ___ TOP
___ 09:25PM ___
___ 09:25PM ___
___ 09:25PM ___
___ 09:25PM cTropnT-<0.01
IMAGES:
======
___ CHEST PA & LAT
IMPRESSION:
Abnormal increased parenchymal opacification of the right upper
and middle
lobes. Main differential considerations include multifocal
infection and/or
hemorrhage.
___ CT CHEST W/O CONTRAST
IMPRESSION:
1. Extensive centrilobular ___ opacities and
consolidations in both
lungs, likely represent multifocal infection and/or alveolar
hemorrhage.
Lymphatic involvement of the lungs is considered less likely.
2. Extensive lymphadenopathy throughout the chest and imaged
upper abdomen is
consistent with history of ___ lymphoma.
3. Mild fluid overload with small right pleural effusion and
small pericardial
effusion.
4. 1.7 x 2.2 cm right adrenal adenoma.
5. 1.4 cm right posterior hepatic lobe hypodensity, potentially
a cyst or
hemangioma, but incompletely characterized. Comparison with
prior imaging is
suggested, and if none available, an ultrasound can be obtained
for further
assessment.
___ BILAT LOWER EXT VEINS
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity
veins.
2. Enlarged bilateral inguinal lymph nodes compatible with known
history of
lymphoma.
___ RENAL US
IMPRESSION:
1. Normal renal ultrasound. No evidence of masses, renal
calculi or
hydronephrosis..
2. Small bilateral pleural effusions, right greater than left.
___ CHEST PORTABLE AP
IMPRESSION:
1. Significant worsening of known pulmonary hemorrhage.
Superimposed
infection cannot be excluded on the basis of this examination.
2. Small left pleural effusion is likely.
___ TTE
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/global biventricular
systolic function. Moderate pulmonary hypertension. The patient
has evidence of high output syndrome (e.g. anemia,
thyrotoxicosis, thiamine deficiency, peripheral shunt, etc.).
___ CXR
Overall improvement of bilateral diffuse ___ opacities
when compared to prior studies, with slightly increased opacity
in right upper lobe which could represent continued bleeding.
Left upper extremity inserted PICC line with the tip at the
cavoatrial junction. There is no pleural effusion or
pneumothorax
PATHOLOGY:
==========
___ MPO ANTIBODIES
>8.0 U
___ PR3 ANTIBODIES
<0.2 U
DISCHARGE LABS:
===============
___ 12:00AM BLOOD ___
___ Plt ___
___ 12:00AM BLOOD ___
___ Im ___
___
___ 12:00AM BLOOD ___
___
___ 12:00AM BLOOD ___ LD(LDH)-323* ___
___
___ 12:00AM BLOOD ___
OTHER PERTINENT LABS
====================
___ 10:55AM BLOOD ___
___ 02:40PM BLOOD cTropnT-<0.01 ___
___ 06:13AM BLOOD ___
___ 02:40PM BLOOD ___
___ 04:41AM BLOOD ___
___ 11:49AM BLOOD ___
___ 04:34AM BLOOD HAV ___
___ 10:55AM BLOOD ___
___ 09:25PM BLOOD ___
___ 07:20PM BLOOD ___
___ 09:25PM BLOOD ___
___ 04:41AM BLOOD ___
___ 04:00PM BLOOD ___ SPECIFI ___
___ Fr ___
___ 09:25PM BLOOD ___
___ 10:55AM BLOOD HIV ___
___ 10:55AM BLOOD HCV ___
___ 05:11AM BLOOD ___
___ Base XS--1 ___ TOP
___ 02:43PM BLOOD ___
___ Base ___ TOP
___ 19:20
CRYOGLOBULIN
Test Result Reference
Range/Units
CRYOGLOBULIN, QL NEGATIVE
CRYOGLOBULIN, QL NEGATIVE
___ 09:49AM BLOOD ___
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD PLUS, INDETERMINATE A NEGATIVE
4T, INCUBATED
___ 09:25PM BLOOD ___
Test Result Reference
Range/Units
GLOMERULAR BASEMENT MEMBRANE <1.0 AI
ANTIBODY (IGG)
___ 09:25PM BLOOD SED ___
Test Result Reference
Range/Units
SED RATE BY MODIFIED 79 H < OR = 30 mm/h
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. ___ Diskus (250/50) 1 INH IH BID
3. FLUoxetine 40 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4h:PRN
6. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atovaquone Suspension 1500 mg PO DAILY PJP prophylaxis
RX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0
3. Azithromycin 250 mg PO/NG 3X/WEEK (___)
RX *azithromycin 250 mg 1 tablet(s) by mouth ___,
___ Disp #*20 Tablet Refills:*0
4. Calcium Carbonate 1000 mg PO DINNER
Do not take with thyroid medication.
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 2
tablet(s) by mouth once a day Disp #*60 Tablet Refills:*0
5. Ensure (food supplemt, ___ 1 unit oral
DAILY:PRN
RX *food supplemt, ___ [Ensure] 1 unit by mouth
daily prn Refills:*0
6. NPH 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [OneTouch Ultra Blue Test Strip]
Please use with the OneTouch meter. four times a day Disp #*120
Strip Refills:*0
RX ___ meter [OneTouch Ultra2 Meter] Please check
your blood glucose at breakfast, lunch, dinner, and bedtime.
Disp #*1 Kit Refills:*0
RX *insulin lispro 100 unit/mL AS DIR Up to 6 Units QID per
sliding scale Disp #*5 Syringe Refills:*0
RX *lancets [OneTouch Delica Lancets] 33 gauge Please use
OneTouch Ultra 2. four times a day Disp #*120 Each Refills:*0
RX *insulin NPH isoph ___ human [Humulin N NPH Insulin
KwikPen] 100 unit/mL (3 mL) AS DIR 20 Units before BKFT; Disp
#*2 Syringe Refills:*0
7. PredniSONE 60 mg PO DAILY vasculitis
Continue until your rheumatology appointment.
8. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 50 mcg (2,000 unit) 1 capsule(s)
by mouth once a day Disp #*30 Capsule Refills:*0
9. FLUoxetine 40 mg PO DAILY
10. ___ Diskus (250/50) 1 INH IH BID
11. Levothyroxine Sodium 112 mcg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4h:PRN
14. HELD- MetFORMIN (Glucophage) 500 mg PO DAILY This
medication was held. Do not restart MetFORMIN (Glucophage) until
instructed by your doctor.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
___ vasculitis
Mantle cell lymphoma
SECONDARY DIAGNOSIS
===================
Acute hypoxic respiratory failure
Paroxysmal atrial fibrillation
___ ventricular tachycardia
Chronic obstructive pulmonary disease
Type II Diabetes Mellitus, insulin dependent
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with hemoptysis// PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
The cardiomediastinal silhouettes are within normal limits. There is
asymmetric increased parenchymal opacification of the right upper and middle
lobes. Lesser patchy opacities also affect the left upper lobe. There is no
pulmonary edema or pneumothorax. Trace bilateral pleural effusions are noted.
No acute osseous abnormality.
IMPRESSION:
Abnormal increased parenchymal opacification of the right upper and middle
lobes. Main differential considerations include multifocal infection and/or
hemorrhage.
RECOMMENDATION(S): Follow-up imaging is appropriate depending on clinical
circumstances to show resolution of opacities within about 8 weeks.
Otherwise, chest CT should be considered.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: History: ___ with hemoptysis// hemorrhage vs infection
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. Heart size
is normal. Coronary artery calcifications are mild. Main pulmonary artery
diameter is within normal limits. There is a small pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: There is extensive, diffuse supraclavicular,
bilateral axillary, mediastinal and bilateral hilar lymphadenopathy,
consistent with history of B-cell lymphoma.
PLEURAL SPACES: There is a small dependent right pleural effusion. No
pneumothorax.
LUNGS/AIRWAYS: There are extensive ground-glass opacities and consolidations
in both lungs in a somewhat centrilobular distribution, associated with
interlobular septal thickening. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: A small, coarse calcification is seen in the left thyroid lobe.
ABDOMEN: There is a small hiatus hernia. A 1.4 cm hypodensity is seen in the
posterior right hepatic lobe (4:218), potentially a cyst or hemangioma,
incompletely characterized. Multiple prominent gastrohepatic and periaortic
lymph nodes are seen. 1.7 x 2.2 cm right adrenal nodule is compatible with an
adenoma.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Extensive centrilobular ground-glass opacities and consolidations in both
lungs, likely represent multifocal infection and/or alveolar hemorrhage.
Lymphatic involvement of the lungs is considered less likely.
2. Extensive lymphadenopathy throughout the chest and imaged upper abdomen is
consistent with history of B-cell lymphoma.
3. Mild fluid overload with small right pleural effusion and small pericardial
effusion.
4. 1.7 x 2.2 cm right adrenal adenoma.
5. 1.4 cm right posterior hepatic lobe hypodensity, potentially a cyst or
hemangioma, but incompletely characterized. Comparison with prior imaging is
suggested, and if none available, an ultrasound can be obtained for further
assessment.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman presenting with shortness of breath with
concern for DVT/PE.// ___ year old woman with concern for DVT/PE.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
Large bilateral inguinal lymph nodes are compatible with known history of
lymphoma.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Enlarged bilateral inguinal lymph nodes compatible with known history of
lymphoma.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: Hemoptysis, dyspnea; rising creatinine// Is there renal
involvement of malignancy?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney:
Left kidney:
The bladder is moderately well distended and normal in appearance. Small
bilateral pleural effusions, right greater than left. A incidentally noted
1.1 cm simple hepatic cyst is noted in the right lobe of the liver.
IMPRESSION:
1. Normal renal ultrasound. No evidence of masses, renal calculi or
hydronephrosis..
2. Small bilateral pleural effusions, right greater than left.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hx lung hemorrhage and tachypnea//
?intraparenchymal hemorrhage, ?worsening lung process
TECHNIQUE: Portable chest AP.
COMPARISON: Chest CT dated ___
FINDINGS:
Low lung volumes. Cardiac silhouette is mildly enlarged. There has been
increased number of ill-defined opacities throughout both lungs suggesting
worsening of the known pulmonary hemorrhage. However, a superimposed
infection cannot be excluded. Small left pleural effusion is likely. No
pneumothorax.
IMPRESSION:
1. Significant worsening of known pulmonary hemorrhage. Superimposed
infection cannot be excluded on the basis of this examination.
2. Small left pleural effusion is likely.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new L PICC// L DL Power PICC 45cm ___
___ Contact name: ___: ___
TECHNIQUE: Portable chest AP.
COMPARISON: Chest radiograph from ___ and ___.
FINDINGS:
Tip of left upper extremity PICC projects over the cavoatrial junction.
Overall similar aeration with redemonstration of bilateral airspace opacities,
similar to the prior study. Trace left pleural effusion. No pneumothorax.
Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
1. Tip of left PICC projects over the cavoatrial junction.
2. Similar radiation with redemonstration of bilateral airspace opacities,
similar to the prior study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pANCA vasculitis, DAH, mantle cell
lymphoma with continued dyspnea on 4LNC/50% shovel mask// ?progression of DAH
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
Overall improvement of bilateral diffuse ill-defined opacities when compared
to prior studies, with slightly increased opacity in right upper lobe which
could represent continued bleeding. Left upper extremity inserted PICC line
with the tip at the cavoatrial junction. There is no pleural effusion or
pneumothorax
IMPRESSION:
Improvement of bilateral diffuse opacities.
Radiology Report
INDICATION: ___ year old woman with mantle cell lymphoma, anca+ vasculitis
needs port for continued treatment// Double lumen chest port placement leave
both accessed for ___ aware
COMPARISON: Chest x-ray dated ___.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of the
procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 20 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 g of Ancef
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 0.06 minutes, 2.4 mGy
PROCEDURE
1. Right internal jugular approach chest double lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The double lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Steri-strips were used to close the
venotomy incision site. Steri-Strips were applied over the sutures. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a double lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Hemoptysis
Diagnosed with Hemoptysis
temperature: 98.6
heartrate: 88.0
resprate: 18.0
o2sat: 95.0
sbp: 159.0
dbp: 62.0
level of pain: 5
level of acuity: 2.0 | SUMMARY
=======
Ms. ___ is a ___ female with COPD, DMII, and
hypothyroidism who presented with dyspnea and hemoptysis,
diagnosed with ___ ANCA vasculitis (positive MPO
antibody), diffuse alveolar hemorrhage, and mantle cell
lymphoma. Her hospital course was complicated by acute hypoxic
respiratory failure and ___ from vasulitis. She was started on
high dose steroids and received Cytoxan/rituximab (___) for both
her vasculitis and lymphoma, and was stable on room air by time
of discharge.
ACUTE ISSUES
============
# ___ Vasculitis
# Hemoptysis
Patient initially presented with one day of hemoptysis. Initial
work up notable for CXR and CT chest showing diffuse alveolar
hemorrhage vs multifocal infection. Given lack of systemic
symptoms (including leukocytosis or fever) or concerning for
infection, this was presumed to be alveolar hemorrhage, which
also fit with her recent hemoptysis. Interventional pulm was
consulted but pt was deemed a poor candidate for bronchoscopy
d/t diffuse nature of pulmonary hemorrhages. Given concurrent
___ and recent epistaxis, vasculitis was considered as etiology
of hemoptysis, and vasculitis labs were sent. Work up notable
for CRP 170, ANCA positive, and myeloperoxidase Ab positive (>8)
consistent with ___ vasculitis. Proteinase 3 Ab
negative, C3/C4 normal, HIV negative, ___ negative, ___
negative, and ___ Abs negative. IgG and IgM returned at
1478 and 60 respectively. Rheumatology, nephrology and
pulmonology were consulted and provided assistance with
management. She was given 1000mg methylpred daily for 3 days
followed by prednisone 80mg/kg. Given concurrent hematologic
malignancy, pt was transferred to ___ service for further
management. Her vasculitis was thought to be a paraneoplastic
workup related to her mantle cell lymphoma, and she was started
on cyclophosphamide, rituximab, and prednisone 100mg daily for
treatment. Following her course of cyclophosphamide and
rituximab, she was continued on 80mg prednisone daily with taper
per rheumatology. Her symptoms, including hemoptysis and
shortness of breath improved with treatment. Additionally, her
kidney function improved and she was weaned to room air. She
will follow up with heme/onc, rheumatology and nephrology for
further management.
#Mantle Cell Lymphoma
Diffuse lymphadenopathy was initially discovered on CT chest at
___, and seen again on repeat CT at ___. A lymph node
biopsy from ___ showed mantle cell lymphoma. Her G6PD was
normal, and she had neg HIV/Hep on workup. On ___, a PICC was
placed, and she was started on rituximab/cyclophosphamide, and
given 100mg prednisone for 4 days (she received 80mg prednisone
on D1). She was also started on atovaquone for PCP ppx, ___
500mg q48h (renally dosed)(switched to azithromycin on ___,
and allopurinol, renally dosed at 100 mg qd. Her PICC was
replaced with a ___ port on ___. She will follow up in
___ clinic for further management.
#Acute hypoxic respiratory distress iso DAH, vasculitis
#COPD
Hospitalization complicated by acute hypoxic respiratory failure
requiring increasing doses of supplemental oxygen, up to 6L NC
and shovel mask, with occasional desaturations into the ___.
These episodes typically resolved with deep breathing. She was
treated with steroids and chemotherapy as above. Additionally,
she received IV Lasix, duonebs q6h and albuterol nebs prn.
Pulmonary was consulted, recommended adding azithromycin 250mg
MWF and acapella TID. Her O2 requirement decreased throughout
her stay and she was on room air by discharge with stable
saturations during ambulation.
#New onset paroxysmal atrial fibrillation
#NSVT
On ___ AM, she noted heart palpitations and increased trouble
breathing. She was found to be in atrial fibrillation on
telemetry and EKG for about 15 minutes. She responded to IV 5mg
bolus of metoprolol, and returned to ___ without symptoms. She
was continued on telemetry for the next week without recurrent
afib. Etiology felt to be ___ acute illness. Anticoagulation and
nodal blockade were deferred given lone episode with obvious
trigger and concern for developing thrombocytopenia.
Additionally, on ___ AM, she had a 20 second run of NSVT with
symptoms. Her electrolytes were repleted. EKG showed no acute
ischemic process. She remained in NSR for the duration of her
stay.
#Anemia
In ED, pt H/H 7.3/24.2, but on following H/H had dropped below
6, she received 2 units pRBCs with good response and H/H
remained stable. Anemia was presumed ___ hemoptysis/diffuse
alveolar hemorrhage, but given resolution of hemoptysis, H/H
remained stable through stay on floor prior to transfer to ___
service. While with BMT, we administered blood products as
needed. Her discharge Hgb was 7.4, and she was transfused 1u
pRBC prior to discharge.
___
In ED, Cr 2 from a baseline of 0.8. Elevated Cr similar to
presentation at ___ one week prior. No hx of kidney
disease. Initial ___ included UA showing proteinuria,
hematuria, 31 WBC, hyaline casts. Renal U/S normal. Initially
presumed ___, given IVF, but pt had concurrent pulmonary
symptoms and recent epistaxis. With concern for systemic
vasculitis, rheumatology and nephrology consulted. Work up
notable for vasculitis as described above. Renal biopsy was
considered, but given tenuous clinical picture and positive
diagnosis by ANCA, was deferred. Nephrology agreed with
rheumatology and heme/onc plan to start high dose steroid course
for 3 days. Medications were renally dosed and nephrotoxic
medications, including NSAIDS, were held. She was also
diuresised with furosemide prn as above. Her Cr continued to
improve during her stay and was 1.6 at time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
Anterior odontoid screw fixation
History of Present Illness:
HPI: ___ s/p mechanical fall, fell off of a 3 foot platform
while
painting in his house and struck his forehead. Occurred 2 days
ago. Has had persistent neck pain since that time.
PMH: Necrotizing pancreatitis with sepsis ___,
insulin-dependent
diabetes
MED: Insulin NovoLog, insulin Lantus, nortriptyline, Ativan,
lisinopril, Prilosec, MiraLax, multivitamins, vitamin C
ALL: NKDA
PE:
Vitals: 98 103 159/91 20 99%
General: NAD
Mental Status: AAOx3
Cranial nerves II-XII grossly intact.
Sensory:
UEC5C6C7C8T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
Rintact intact intact intact intact
Lintact intact intact intact intact
T2-L1 (Trunk) intact
___ L2 L3 L4 L5S1S2
(Groin)(Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
Rintactintactintactintact intactintact
Lintact intactintactintact intactintact
Motor:
UEDlt(C5)Bic(C6)WE(C6)Tri(C7)WF(C7)FF(C8)FinAbd(T1)
R 5 5 5 5 ___
L 5 5 5 5 ___
___ Flex(L1)Add(L2)
___
R ___ 5 5 5 5
L 5 5 5 5 5 5 5
Reflexes
Bic(C4-5)BR(C5-6)Tri(C6-7)Pat(L3-4)Ach(L5-S1)
R 1 1 1 1 1
L 1 1 1 1 1
Estimated Level of Cooperation: good
Estimated Reliability of Exam: good
LABS:
IMAGING: CT C-spine wet read: Type II dens fracture is
displaced
anteriorly by 4 mm. Complete fracture through the anterior arch
of C1, and bilateral posterior arches ___ burst
fracture).
Moderate to severe multi-level DJD.
IMPRESSION & RECOMMENDATIONS: ___ s/p fall, with dens fracture
and C1 arch fratures, neurologically intact. We will take to OR
today vs. tomorrow for ORIF of dens. Discussed surgery,
benefits, risks, alternatives at length with patient and wife
and
obtained informed consent
Past Medical History:
see HPI
Social History:
___
Family History:
see HPI
Physical Exam:
see HPI
Pertinent Results:
___ 03:35PM GLUCOSE-209* UREA N-22* CREAT-1.2 SODIUM-134
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-26 ANION GAP-16
___ 03:35PM estGFR-Using this
___ 03:35PM CALCIUM-10.7* PHOSPHATE-3.3 MAGNESIUM-1.9
___ 03:35PM WBC-8.7 RBC-4.92 HGB-15.8 HCT-48.8 MCV-99*
MCH-32.0 MCHC-32.3 RDW-13.2
___ 03:35PM PLT COUNT-263
___ 03:35PM ___ PTT-30.9 ___
Medications on Admission:
Insulin NovoLog sliding scale, insulin Lantus 28 units QHS,
nortriptyline 50 TID, Ativan 1 BID, lisinopril 5 daily, Prilosec
40 daily, multivitamins, vitamin C 1000 daily
Discharge Medications:
1. nortriptyline 25 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. ascorbic acid ___ mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain/fever.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. oxycodone 5 mg Tablet Sig: 1 to 3 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
11. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
BID (2 times a day) for 4 days.
Disp:*1 bottle* Refills:*0*
12. pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
13. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Type 2 Dens fracture.
Undisplaced ___ fracture
Frontal bone fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man status post fall, landing on head, presenting
with neck pain, dizziness, persistent cervical pain; evaluate for bleed.
TECHNIQUE: MDCT data were acquired through the head without intravenous
contrast. Images were reconstructed using bone and soft tissue kernels and
displayed in multiple planes.
FINDINGS: There is a non-displaced fracture through the midline of the
frontal bone (3:36-41). The fracture extends into both frontal air cells,
where there are slight cortical step-offs (3:22); there is also involvement of
the right paramedian "inner table" of the left frontal air cell, though there
is no pneumocephalus at this site or elsewhere. There is blood and air
filling the frontal sinuses and extending into the left anterior ethmoid air
cells. There is hyperdense fluid layering and air-fluid levels in both
maxillary air cells as well as air mixed in the right. The density suggests
that this is blood. No orbital or other fracture is identified as the lead
point. Hyperdense fluid also layers mixed with air in both sphenoid sinuses.
There is no large subgaleal or other superficial hematoma.
IMPRESSION:
1. No acute intracranial process.
2. Non-displaced midline frontal bone fracture with blood in the frontal,
maxillary and sphenoid sinuses. A maxillofacial CT has been suggested for
further evaluation of these and any additional facial fractures.
NOTE ADDED IN ATTENDING REVIEW: There is no intra- or extra-axial hemorrhage
or evidence of cerebral edema. No pneumocephalus is seen.
Radiology Report
INDICATION: ___ man status post fall from ___ steps, landing on head,
now with persistent neck pain.
FINDINGS: A type II dens fracture is displaced anteriorly, approximately 4
mm. There is ___ burst-type fracture of C1. There are fractures of
the anterior arch and bilateral posterior arches of C1 (2:15). The remainder
of the cervical spine is well aligned. There are no additional cervical spine
fractures. Degenerative changes are mild to moderate. There is severe loss
of disc height at C4-C5 accompanied by left-sided facet fusion at this level.
Mild multilevel posterior disc osteophyte complexes do not cause more than
mild spinal canal narrowing at any level. There is mild prevertebral soft
tissue swelling at the C1 level. Otherwise, there is no pre- or
para-vertebral soft tissue swelling. The airway is patent. The visualized
lung apices are clear.
IMPRESSION:
1. Displaced type II fracture of the odontoid process, with 4 mm anterior
displacement of the distal dens fragment, but no spinal canal compromise.
2. ___ burst fractures of the anterior and posterior neural arches
of C1, again without canal compromise.
3. Multilevel degenerative disease with foraminal but no "critical" canal
stenosis.
Radiology Report
INDICATION: ___ man status post 3-feet fall from platform, presenting
with headache, facial pain, neck pain.
COMPARISONS: Head and C-spine CT earlier same day demonstrating a midline
frontal fracture and extensive sinus opacification.
TECHNIQUE: Contiguous MDCT data were acquired through the frontal sinuses.
Images were reconstructed using bone and soft tissue kernels. Images were
displayed in multiple planes.
FINDINGS: A non-displaced midline fracture through the frontal bone to the
frontal sinus is re-demonstrated. There is hyperdense blood and air in the
frontal sinus and anterior left ethmoid air cells. Additional hyperdense
fluid and air with air-fluid levels are seen in the maxillary and sphenoid
sinuses. A ___ burst fracture of C1 is seen at the lower edge of the
field of view but better visualized on preceding C-spine CT. Osteomeatal
units are patent bilaterally. The cribriform plates and lamina papyracea are
intact.
IMPRESSION: Re-demonstration of non-displaced midline frontal bone fracture
and C1 ___ burst fracture. No additional fractures. Extensive fluid
and air in the maxillary and sphenoid sinuses may represent the sequela of
acute sinusitis or additional blood.
Radiology Report
CHEST RADIOGRAPH performed on ___.
___.
CLINICAL HISTORY: Preop chest radiograph.
COMPARISON: None.
FINDINGS: PA and lateral views of the chest are obtained. Lungs are clear.
No focal consolidation, effusion or pneumothorax. Cardiomediastinal
silhouette is normal. Bony structures appear intact.
IMPRESSION: No acute intrathoracic process.
Radiology Report
STUDY: Cervical ___.
CLINICAL HISTORY: Patient with ORIF of C2.
FINDINGS: Comparison is made to the CT scan from ___.
AP and lateral views of the upper cervical spine demonstrates placement of a
screw through the fracture involving the dens of C2. There is good
positioning and no signs of hardware-related complications. Please refer to
the operative note for additional details.
Radiology Report
CERVICAL SPINE 2 VIEWS: ___.
HISTORY: ___ male with odontoid screw fixation.
FINDINGS: AP and lateral views of the cervical spine are compared to previous
intraop films from ___. The odontoid screw is identified
transfixing the odontoid fracture. There is no evidence of new displaced
fracture based on plain film. Known C1 ___ type burst fracture is not
well seen on the current exam. The other vertebral bodies are maintained in
height and alignment throughout noting degenerative changes in the
mid-to-lower cervical spine as previously detailed. Mild prevertebral soft
tissue swelling seen at the C1-C2 level, not unexpected given patient's recent
postoperative state.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NECK PAIN.HA S/P FALL
Diagnosed with FX C2 VERTEBRA-CLOSED, FALL-1 LEVEL TO OTH NEC, FX C1 VERTEBRA-CLOSED, CLOSED SKULL VAULT FX, HYPERTENSION NOS, DIABETES UNCOMPL JUVEN
temperature: 98.0
heartrate: 103.0
resprate: 20.0
o2sat: 99.0
sbp: 159.0
dbp: 91.0
level of pain: 9
level of acuity: 2.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#1.
Physical therapy was consulted for mobilization OOB to ambulate.
Plastic surgery was consulted for frontal bone fractures. They
did not recommend any further intervention or follow-up for your
fractures.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenobarbital / levofloxacin
Attending: ___.
Chief Complaint:
Right-sided Chest Pain, Dyspnea, Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with DM, COPD, peripheral vascular disease with
claudication and polymyalgia rheumatica presenting with right
sided chest pain.
Pt states that she fell two weeks ago, tripped over baby's
walker, landed on the L side. She reports R-sided chest pain
started two days ago. She describes the pain as sharp and
stabbing worsened with breathing and movement. She denies any
radiation of the pain and associated dyspnea, diaphoresis,
nausea, or vomiting. The pain is intermittent and only improved
with standing still. She also reports associated dyspnea,
increased cough and sputum production compared to her baseline.
She denies any fevers, chills, nausea, or vomiting. The patient
continued to take her oxycodone for her chronic back pain, but
has not provided any relief in her R-sided chest pain. She
continues to smoke, denies any recent travels or sick contacts.
In the ED, initial VS were 99.4 HR: 91 BP: 131/75 Resp: 20
O(2)Sat: 95 on 3L NC. Exam was most notable for pain in right
upper lateral aspect of chest that was reproducible by palpation
and both active and passive motions. CXR was notable for L-sided
atelectasis. EKG was unchanged from baseline and trop negative
x3. CTA was negative for PE. There was an initial concern for
COPD exacerbation and pneumonia, thus the patient was given
Prednisone and Azithromycin as well as IV Ceftriaxone.
On the floor, the patient continued to complain of right-sided
chest wall pain. She also endorsed dyspnea and increased
productive cough. Otherwise, she denied any palpitations,
lightheartedness, lower extremity edema, fevers, chills, nausea,
or vomiting.
Past Medical History:
ADULT ONSET DIABETES MELLITUS ___
CARPAL TUNNEL SYNDROME
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
COLONIC ADENOMA ___
one
DEPRESSION
hospitalized ___
DYSPHAGIA ___
GASTROESOPHAGEAL REFLUX 92
HYPERCHOLESTEROLEMIA ___
SMOKER
SOCIAL
daughter died of AIDS, hx abusive relationship, grandaughter
died age ___ AML
STRESS INCONTINENCE 96
LOW BACK PAIN ___
MRI 03 Degenerative disease at multiple levels (degenerative
disc and spine
disease)
PERIPHERAL VASCULAR DISEASE
legs , severe pvd on doppler, claudication
POLYMYALGIA RHEUMATICA
Social History:
___
Family History:
Depression, no other medical problems reported
Physical Exam:
ON ADMISSION:
VS T 98.7 HR 73 BP 110/67 RR 22 SpO2 93% 5L NC
General: Patient in pain in mild distress
HEENT: Sclera clear, MMM, no oropharyngeal lesions
Neck: Supple, no JVD, no cervical lymphadenopathy
CV: RRR, no m,r,g. Normal S1 and S2.
Chest: Pain on palpation of R upper lateral chest wall worsened
with movement. No erythema or dermatomal rashes. No ecchymoses.
Lungs: R base inspiratory crackles, otherwise no wheezing or
rhonci.
Abdomen: Soft, NT, ND. +Normoactive bowel sounds.
Ext: Warm, well-perfused. No ___ edema.
Neuro: Moving all extremities with purpose. No facial assymetry.
Skin: No rashes, ecchymoses, or petechiae.
ON DISCHARGE:
VS T 98.4 HR 87 BP 127/85 RR 18 ___ NC
General: Patient in pain in mild distress
HEENT: Sclera clear, MMM, no oropharyngeal lesions
Neck: Supple, no JVD, no cervical lymphadenopathy
CV: RRR, no m,r,g. Normal S1 and S2.
Chest: Mild to moderate on palpation of R upper lateral chest
wall worsened with movement. No erythema or dermatomal rashes.
No ecchymoses.
Lungs: R base inspiratory crackles, otherwise no wheezing or
rhonci.
Abdomen: Soft, NT, ND. +Normoactive bowel sounds.
Ext: Warm, well-perfused. No ___ edema.
Neuro: Moving all extremities with purpose. No facial assymetry.
Skin: No rashes, ecchymoses, or petechiae.
Pertinent Results:
ON ADMISSION:
___ 03:12PM BLOOD WBC-15.4* RBC-4.35 Hgb-13.5 Hct-41.3
MCV-95 MCH-30.9 MCHC-32.6 RDW-14.8 Plt ___
___ 03:12PM BLOOD Neuts-80.0* Lymphs-13.2* Monos-5.8
Eos-0.6 Baso-0.3
___ 03:12PM BLOOD Plt ___
___ 03:12PM BLOOD Glucose-198* UreaN-26* Creat-1.3* Na-138
K-4.7 Cl-98 HCO3-28 AnGap-17
___ 03:12PM BLOOD cTropnT-<0.01
___ 03:22PM BLOOD Lactate-1.8
ON DISCHARGE:
___ 07:00AM BLOOD WBC-7.1# RBC-3.56* Hgb-11.1* Hct-34.5*
MCV-97 MCH-31.3 MCHC-32.2 RDW-14.8 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-83 UreaN-25* Creat-1.3* Na-143
K-5.1 Cl-100 HCO3-33* AnGap-15
___ 07:00AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.4*
IMAGING:
CT C-SPINE W/O CONTRAST ___:
IMPRESSION:
1. No acute cervical spine fractures identified. Moderate to
severe
degenerative changes seen throughout the cervical spine.
2. Partial atelectasis of the left upper lobe is better
evaluated on the dedicated CT of the chest performed on the same
day.
CT HEAD W/O CONTRAST ___:
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass
effect or acute large territorial infarction. Periventricular,
and subcortical white matter hypodensities, is likely secondary
to age related small vessel ischemic disease. The ventricles and
sulci are normal in size and configuration. The basilar cisterns
are patent, and there is otherwise good preservation of the
gray-white matter differentiation.
No acute fracture is identified. There is mild mucosal polypoid
thickening along the sphenoid sinus. The visualized paranasal
sinuses are otherwise unremarkable. The mastoid air cells, and
middle ear cavities are clear. The globes are unremarkable.
IMPRESSION:
No acute intracranial abnormalities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. BuPROPion (Sustained Release) 100 mg PO QAM
3. Divalproex (DELayed Release) 250 mg PO BID
4. Fluoxetine 40 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Furosemide 20 mg PO DAILY
7. Guaifenesin ___ mL PO Q6H:PRN cough
8. Omeprazole 20 mg PO BID
9. OxycoDONE (Immediate Release) 15 mg PO 5X/DAY pain
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. PredniSONE 10 mg PO 2X/WEEK (MO,FR)
12. Propranolol 60 mg PO DAILY
13. Simvastatin 40 mg PO DAILY
14. TraZODone 150 mg PO HS:PRN insomnia
15. Tiotropium Bromide 1 CAP IH DAILY
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
17. Calcium Carbonate 200 mg PO QID:PRN heartburn
18. cilostazol 100 mg ORAL BID
19. GlipiZIDE 2.5 mg PO DAILY
20. MetFORMIN (Glucophage) 500 mg PO BID
21. Nicotine Lozenge 4 mg PO DAILY
22. PredniSONE 7.5 mg PO 5X/WEEK (___)
23. Vitamin D 1000 UNIT PO DAILY
24. Cepastat (Phenol) Lozenge 1 LOZ PO Q6H:PRN throat pain
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. BuPROPion (Sustained Release) 100 mg PO QAM
3. Calcium Carbonate 200 mg PO QID:PRN heartburn
4. Cepastat (Phenol) Lozenge 1 LOZ PO Q6H:PRN throat pain
5. cilostazol 100 mg ORAL BID
6. Divalproex (DELayed Release) 250 mg PO BID
7. Fluoxetine 40 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Furosemide 20 mg PO DAILY
10. Guaifenesin ___ mL PO Q6H:PRN cough
11. Nicotine Lozenge 4 mg PO DAILY
12. Omeprazole 20 mg PO BID
13. OxycoDONE (Immediate Release) 15 mg PO 5X/DAY pain
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. PredniSONE 10 mg PO 2X/WEEK (MO,FR)
16. PredniSONE 7.5 mg PO 5X/WEEK (___)
17. Propranolol 60 mg PO DAILY
18. Simvastatin 40 mg PO DAILY
19. TraZODone 150 mg PO HS:PRN insomnia
20. Vitamin D 1000 UNIT PO DAILY
21. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
22. GlipiZIDE 2.5 mg PO DAILY
23. MetFORMIN (Glucophage) 500 mg PO BID
24. Tiotropium Bromide 1 CAP IH DAILY
25. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*12 Tablet Refills:*0
26. Azithromycin 500 mg PO Q24H Duration: 6 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth once daily Disp #*6
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with right chest pain and cough. history of COPD.
COMPARISON: Prior chest radiograph from ___. CTA chest performed
concurrently.
FINDINGS:
AP upright and lateral views of the chest provided. The lungs appear
hyperinflated with left mid lung opacity which is compatible with atelectasis
better assessed on the CTA performed concurrently. Emphysematous changes are
noted. No large effusion or pneumothorax. Cardiomediastinal silhouette appears
stable. Bony structures are intact.
IMPRESSION:
Emphysema, left mid lung atelectasis. Please refer to subsequent CTA chest for
further details.
Radiology Report
INDICATION: ___ with right humerus pain status post fall.
COMPARISON: None
FINDINGS:
Two views of the right humerus were provided. No fracture is identified.
Degenerative spurring is seen along the inferior aspect of the right humeral
head. Subchondral cystic changes are present within the humeral head. There is
right AC joint arthropathy with productive bony changes noted. Limited views
of the right elbow are unremarkable. No soft tissue injuries are seen.
IMPRESSION:
Degenerative changes without acute fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History of fall. Please evaluate for intracranial hemorrhage.
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
CTDIvol: 54 mGy
DLP: 891 mGy-cm
COMPARISON: None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect or acute
large territorial infarction. Periventricular, and subcortical white matter
hypodensities, is likely secondary to age related small vessel ischemic
disease. The ventricles and sulci are normal in size and configuration. The
basilar cisterns are patent, and there is otherwise good preservation of the
gray-white matter differentiation.
No acute fracture is identified. There is mild mucosal polypoid thickening
along the sphenoid sinus. The visualized paranasal sinuses are otherwise
unremarkable. The mastoid air cells, and middle ear cavities are clear. The
globes are unremarkable.
IMPRESSION:
No acute intracranial abnormalities.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History of fall 2 weeks prior. Please evaluate for fracture.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 37 mGy
DLP: 720 mGy-cm
COMPARISON: None
FINDINGS:
There is no evidence of acute cervical spine fracture, malalignment, or
prevertebral soft tissue swelling.
Moderate to severe degenerative changes are seen throughout the cervical spine
with evidence of intervertebral disc space narrowing, severe subchondral
sclerosis and subchondral cysts, and anterior/ posterior osteophytosis. There
is mild thecal sac narrowing, secondary to intervertebral disk protrusion
worse from C2/C3, and C6/C7. The thyroid is normal. There is no cervical
lymphadenopathy. The visualized left maxillary sinus demonstrates polypoid
mucosal sinus thickening. Partial left upper lobe atelectasis is better
evaluated on the recent CT of the chest performed on the same day.
IMPRESSION:
1. No acute cervical spine fractures identified. Moderate to severe
degenerative changes seen throughout the cervical spine.
2. Partial atelectasis of the left upper lobe is better evaluated on the
dedicated CT of the chest performed on the same day.
Radiology Report
EXAMINATION: CTA chest.
INDICATION: History shortness of breath, chest wall pain. Please evaluate.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque intravenous
contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: DLP: 396 mGy-cm
COMPARISON: CT from ___.
FINDINGS:
The thyroid is normal. There is no axillary, hilar, or supraclavicular
lymphadenopathy. There is mild prominence of the mediastinal lymph nodes,
measuring up to 1 cm, series 2, image 40. The heart size is normal. There is
no evidence of a pericardial effusion. Note is made of mild atherosclerotic
calcification of the coronary arteries, as well as moderate annular
calcifications. There is a small hiatal hernia. The esophagus is otherwise
unremarkable without evidence of wall thickening.
CTA: The aorta is normal without evidence of aneurysm or dissection. Mild
enlargement of the main, and right pulmonary arteries is unchanged compared to
the prior exam, consistent with pulmonary hypertension. The main, lobar,
segmental, and subsegmental pulmonary arteries, are well opacified without
evidence of filling defects concerning for a pulmonary embolus.
There is new partial atelectasis of the left upper lobe. A 5 mm nodule is seen
in the posterior right upper lobe (series 3, image 56), new compared to the
prior exam. Note is made of mild bronchiectasis with subtle areas of mucoid
impaction, (series 3 image 68) overall similar to the prior exam. Note is made
of a granuloma at the left lower lobe series 3, image 98. Left lower lobe
nodule measuring 6 mm, series 3, image 145 is new compared to the prior exam.
There is no pleural effusion or pneumothorax.
This study is not tailored for the evaluation of the subdiaphragmatic
structures the however hypodensities within the liver are too small to
characterize by CT, and likely secondary dose simple hepatic cyst. The 1.3 cm
hypodense lesion in the superior pole of the left kidney is unchanged compared
to the prior exam, and too small to characterize by CT. No acute
intra-abdominal abnormalities identified.
OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are
identified.
IMPRESSION:
1. No evidence of a pulmonary embolism or aortic abnormality.
2. New partial atelectasis of the left upper lobe, is likely secondary to
bronchial impaction. A superimposed infectious process cannot be excluded.
3. New 6 mm nodule in the left lower lobe (3;98). A six-month followup is
recommended for further evaluation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with CHEST PAIN NEC, RESPIRATORY ABNORM NEC
temperature: 99.4
heartrate: 91.0
resprate: 20.0
o2sat: 95.0
sbp: 131.0
dbp: 75.0
level of pain: 9.5
level of acuity: 2.0 | ___ yo F with DM, COPD, peripheral vascular disease with
claudication and polymyalgia rheumatica presenting with right
sided chest pain.
# Right-sided Chest Pain: On exam, pain is reproducible with
movement and palpation. Presentation likely due to
costochondritis. No evidence of ACS or pericarditis given
unremarkable EKG and cardiac biomarkers. CXR notable for L-sided
atelectasis. CTA negative for PE. No dermatomal rash to suggest
Zoster.
She was managed with Tylenol, lidocaine patch, and continued on
her hme oxycodone. NSAIDs were avoided given CKD. The patient
had mild improvement in her symptoms at the time of discharge.
She was discharged with Lidocaine patches for her pain.
# Pneumonia: Exam most notable for inspiratory crackles at RLL,
dyspnea, and increased sputum production concerning for
pneumonia. Initial labs most notable for leukocytosis to 15.
Patient recently hospitalized in ___, patient meets
criteria for HCAP. Chest CT notable for pulmonary nodules with
atelectasis concerning for possible post-obstructive pneumonia.
The patient received IV Ceftriaxone in the ED. The patient was
subsequently transitioned to Augmetin 875 mg PO BID x 10 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
Teeth extraction with OMFS
History of Present Illness:
___ year old male has ETOH cirrhosis complicated by varices,
ascites, SBP on cipro prophylaxis, listed for liver txp with
MELD
30, GAD, OA of bilateral hips s/p right THR (___) presenting
for
hyponatremia iso recent decrease in diuretic dose. Multiple
recent admissions for hyponatremia and volume overload, most
recently last week. His labs from ___ came back with sodium 124
and we recommended he come into the ED but he declined, wanted
to
see his liver doctor ___ in clinic today. At clinic, repeat
sodium was 123, so they sent him to the ED. In the ED, sodium
worsened to 117, has been improving (now ___ with diuresis. Per
renal team, volume overloaded, so now diuresing. No pocket of
ascites to target on bedside U/S per ED.
Past Medical History:
Alcohol use disorder
Alcoholic cirrhosis c/b grade 1 varies, new onset ascites, SBP
Gout
GAD
HTN
Avascular necrosis of hips bilaterally s/p hip arthroplasty on R
Bilateral inguinal hernia report
MDD
SDH (___)
Social History:
___
Family History:
Heart disease/AD/HTN in father, ___ cancer in mother, heart
disease in brother
Physical Exam:
Admission Physical Exam
=======================
VITALS:
___ 1613 Temp: 98.1 PO BP: 134/55 L Lying HR: 71 RR: 20 O2
sat: 100% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
General: AO x 3 no acute distress
HEENT: scleral icterus present
CV: systolic murmur loudest at right sternal border.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mildly distended, no rebound or
guarding
Ext: Mild peripheral edema.
Skin: Slightly jaundiced
Neuro: Able to move limbs approrpiately
Discharge Physical Exam
=======================
General: Well-appearing. In no acute distress
HEENT: Scleral icterus. Right sided jaw swelling with ecchymosis
on right side, under jaw and small area on left.
Cardiac: Systolic murmur ___ appreciated at right sternal border
Respiratory: Lungs clear to auscultation bilaterally
Derm: Jaundiced
Abdomen: Mildly distended. Nontender to palpation. Prominent
ventral hernia.
Peripheral: 1+ bilateral ___ edema
Pertinent Results:
Admission Labs:
===============
___ 10:30AM BLOOD WBC-3.8* RBC-2.68* Hgb-9.0* Hct-25.9*
MCV-97 MCH-33.6* MCHC-34.7 RDW-15.4 RDWSD-55.3* Plt Ct-35*
___ 10:30AM BLOOD Plt Ct-35*
___ 10:30AM BLOOD ___
___ 10:30AM BLOOD UreaN-12 Creat-0.6 Na-123* K-4.7 Cl-88*
HCO3-21* AnGap-14
___ 10:30AM BLOOD ALT-27 AST-68* AlkPhos-183* TotBili-8.5*
Imaging:
========
CT Head Non-contrast ___:
IMPRESSION:No evidence of acute intracranial abnormality
identified on noncontrast head
CT.
CT Chest with contrast ___:
No evidence of metastasis to the chest.
Moderate-sized hiatus hernia. Paraesophageal varices.
Evidence of cirrhosis with portal hypertension. Multiple
collaterals within the upper abdomen.
Ill-defined hypodense lesion within the right lobe of liver has
been better characterized by an MRI done on ___.
CXR ___:
1. No pneumonia.
2. Mild enlargement of the cardiac silhouette and previously
noted mild
pulmonary edema are improved from ___.
Discharge Labs:
===============
___ 06:20AM BLOOD WBC-1.8* RBC-2.07* Hgb-7.1* Hct-22.2*
MCV-107* MCH-34.3* MCHC-32.0 RDW-16.3* RDWSD-63.0* Plt Ct-31*
___ 06:20AM BLOOD Neuts-39.6 Lymphs-18.1* Monos-23.7*
Eos-16.4* Baso-1.1* Im ___ AbsNeut-0.70* AbsLymp-0.32*
AbsMono-0.42 AbsEos-0.29 AbsBaso-0.02
___ 06:20AM BLOOD Plt Ct-31*
___ 06:20AM BLOOD ___ PTT-40.2* ___
___ 06:20AM BLOOD Glucose-101* UreaN-12 Creat-0.6 Na-132*
K-4.1 Cl-97 HCO3-26 AnGap-9*
___ 06:20AM BLOOD ALT-26 AST-59* LD(LDH)-267* AlkPhos-137*
TotBili-5.1*
___ 06:20AM BLOOD Albumin-4.1 Calcium-9.1 Phos-3.6 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild/Fever
2. Bisacodyl ___ID:PRN Constipation - Second Line
3. Cholestyramine 4 gm PO BID
4. Ciprofloxacin HCl 500 mg PO Q24H
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 30 mL PO QID
7. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. rifAXIMin 550 mg PO BID
10. Spironolactone 100 mg PO BID
11. TraZODone 50-100 mg PO QHS:PRN insomnia
12. Ursodiol 300 mg PO BID
13. Torsemide 10 mg PO DAILY
14. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Aminocaproic Acid 25 % Oral Rinse 5 gm PO TID
RX *aminocaproic acid [Amicar] 250 mg/mL 20 ml by mouth twice a
day Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*18 Tablet Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine (bulk) Hold in mouth for as long as can
tolerate Two times per day prior to Amicar Refills:*0
4. Tolvaptan 30 mg PO QAM
RX *tolvaptan [Jynarque] 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Acetaminophen 500 mg PO DAILY:PRN Pain - Mild/Fever
6. Bisacodyl ___ID:PRN Constipation - Second Line
7. Cholestyramine 4 gm PO BID
8. Ciprofloxacin HCl 500 mg PO Q24H
9. FoLIC Acid 1 mg PO DAILY
10. Lactulose 30 mL PO QID
11. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
13. rifAXIMin 550 mg PO BID
14. Thiamine 100 mg PO DAILY
15. TraZODone 50-100 mg PO QHS:PRN insomnia
16. Ursodiol 300 mg PO BID
17. HELD- Spironolactone 100 mg PO BID This medication was
held. Do not restart Spironolactone until you talk with your
liver doctors
18. HELD- Torsemide 10 mg PO DAILY This medication was held. Do
not restart Torsemide until you discuss with your liver doctors
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Hyponatremia
Secondary Diagnosis
===================
ETOH Cirrhosis c/n varices
Tooth Infection
Insomnia
Chronic Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough,volume overload// eval for pna
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest radiograph from ___.
FINDINGS:
Mild enlargement of the cardiac silhouette and previously noted mild pulmonary
edema are improved.: Less no opacification in the right lower lobe was present
on ___, 9, and 20 second and could be either due asymmetric edema or
concurrent pneumonia.. There is no pleural abnormality.
IMPRESSION:
1. Possible right lower lobe pneumonia.
2. Mild enlargement of the cardiac silhouette and previously noted mild
pulmonary edema are improved from ___.
NOTIFICATION: The findings were discussed with ___ Resident ___, by
___, M.D. on the telephone at 08:00 immediately following discovery of
the findings.
IMPRESSION:
1. No pneumonia.
2. Mild enlargement of the cardiac silhouette and previously noted mild
pulmonary edema are improved from ___.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with cirrhosis// eval for PVT, ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRI liver from ___.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. A 1.8 cm hypoechoic nodule in
the right hepatic lobe likely corresponds to dysplastic nodule seen on prior
MRI study. The main portal vein is patent with hepatopetal flow. The right
anterior and posterior portal veins are patent, although slow flow is seen
within the right posterior portal vein. The left portal vein is patent, but
has reversed flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 5 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 16.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 12.5 cm
Left kidney: 12.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with splenomegaly. No ascites.
2. Patent portal veins, although there is slow flow in the right posterior
portal vein and reversed direction flow in the left portal vein.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis here for hyponatremia// rule out
infection, mass, lesion
IMPRESSION:
In comparison with the study of ___, the questioned increased
opacification at the right base is no longer seen. There is the vague
suggestion of some increased opacification at the left base. This could
merely represent atelectatic changes, though in the appropriate clinical
setting a developing aspiration could be considered.
Cardiomediastinal silhouette is stable. There is minimal indistinctness of
pulmonary vessels that could represent mild elevation in pulmonary venous
pressure. No evidence of pleural effusion.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with encepholopathy and hypoNa// Any lung masses
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 39.2 cm; CTDIvol = 16.4 mGy (Body) DLP = 640.6
mGy-cm.
Total DLP (Body) = 641 mGy-cm.
COMPARISON: No prior CT chest is available for comparisons.
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes. Note is made
of a bilateral gynecomastia.
MEDIASTINUM: There are no enlarged mediastinal hilar lymph nodes. Heart size
is normal. There is moderate coronary artery calcification. There is a
moderate-sized hiatus hernia. There is no pericardial effusion. The aorta
and pulmonary arteries are normal in caliber.
PLEURA: There is no pleural effusion. There is no pericardial effusion.
LUNG: There is minimal bibasilar atelectasis. No lung nodules are seen.
BONES AND CHEST WALL : Review of bones shows no lytic or sclerotic lesions
concerning for metastasis.
UPPER ABDOMEN: Limited sections through the upper abdomen shows evidence of
cirrhosis with portal hypertension. Multiple collaterals are seen within the
gastrohepatic ligament and also along the esophagus. There is an ill-defined
hypodense lesion within segment 7 of the liver. Multiple collaterals are seen
in the upper abdomen (2, 67).
IMPRESSION:
No evidence of metastasis to the chest.
Moderate-sized hiatus hernia. Paraesophageal varices.
Evidence of cirrhosis with portal hypertension. Multiple collaterals within
the upper abdomen.
Ill-defined hypodense lesion within the right lobe of liver has been better
characterized by an MRI done on ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with ETOH cirrhosis complicated by varices,
ascites, SBP, presenting for asymptomatic hyponatremia despite on tolvaptan.
Evaluation for pathology to explain possible SIADH.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Comparison to noncontrast head CT from ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, acute large territorial
infarction, edema,or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes. Periventricular and subcortical
hypodensities are nonspecific, though likely sequela of chronic small vessel
ischemic disease.
There is no evidence of fracture. There is an unchanged chronic defect in the
left lamina papyracea and an atelectatic left maxillary sinus. The visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality identified on noncontrast head
CT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal sodium level
Diagnosed with Hypo-osmolality and hyponatremia
temperature: 98.2
heartrate: 72.0
resprate: 16.0
o2sat: 98.0
sbp: 155.0
dbp: 52.0
level of pain: 7
level of acuity: 2.0 | PATIENT SUMMARY
===============
___ year old male has ETOH cirrhosis complicated by varices,
ascites, SBP on cipro prophylaxis, listed for liver txp with
MELD
30, GAD, OA of bilateral hips s/p right THR (___) presenting
for
hyponatremia. His tolvaptan dose was uptitrated to 30mg daily
with stabilization of serum Na. He maintained euvolemia on this
dose of Tolvaptan without any other diuretics and thus his home
diuretics were held on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"I don't know why I am here"
Major Surgical or Invasive Procedure:
CBI in ED
History of Present Illness:
Patient is a ___ y/o male with htn, dementia, hypothyroidism,
referred from admission after his NH found blood in toilet - ?
if from stool or urine so they sent him to the emergency room.
He was found to be retaining urine in ___ staff reported to RN
that over past 3 weeks he has been much more confused, is eating
less and has lost 25 lbs.
Patient is very confused on exam, and cannot provide any
information as to why he is in hospital nor as to prior
symptoms. At present, he denies nausea, vomiting, sob, cp, ha,
abdominal pain, fevers. 10 point ROS otherwise negative. Per
RN, he was having frequent diarrhea in ED.
Past Medical History:
-Dementia, hypothyroid, HTN
-Remote history of prostate and breast cancer. Sister believes
he had radiation for prostate cancer and possibly surgery, but
she is not sure. She reports mastectomy for breast cancer.
Social History:
___
Family History:
He is unable to provide
Physical Exam:
ADMISSION PHYSICAL EXAM
98.3 155 / 70 67 18 99 RA
Gen: Thin older gentleman, pleasant, not agitated, NAD
HEENT: ? exophthalmos
No palpable thyroid
CV: RRR
Abd: Nabs, soft, mild distesion, no hsm
Foley in place draining slightly blood tinged urine
Ext: no edema
No cervical ___: Oriented to person, city only. Follows commands, but
provides incoherent answers to all other questions. For
example, "here to watch the turkeys". He likes that "it is not
too crowded here".
DISCHARGE PHYSICAL EXAM
-Vitals: 99.3F, HR 78, BP 150/84, RR 18, SpO2 99$
-General: pleasant, lying in bed
-HEENT: Anicteric, moist mucus membranes, exopthalmous
-Cardiovascular: RRR, no murmur
-Pulmonary: clear b/l, no wheeze
-Gastroinestinal: Soft, non-tender, distended, bowel sounds
present, obese
-GU: in the morning foley with clear urine and clots settled at
the bottom of the bag. No suprapubic tenderness. In the
afternoon patient without foley and no change in exam.
-MSK: No edema
-Skin: No rashes or ulcerations evident
-Neurological: AAO to self, no focal neurological deficits
otherwise
-Psychiatric: pleasant, appropriate affect
Pertinent Results:
Head CT
There is no definite evidence of subacute infarcts, although,
underlying
moderate to severe chronic small vessel ischemic changes
decreased sensitivity of this exam in detecting deep white
matter subacute infarcts.
There is generalized brain parenchymal atrophy. 2 subtle foci of
abnormality in the anterior frontal lobes are likely an
artifact. Paranasal sinus disease, as above.
___ 07:30AM BLOOD WBC-11.3* RBC-4.11* Hgb-10.6* Hct-33.6*
MCV-82 MCH-25.8* MCHC-31.5* RDW-13.5 RDWSD-40.6 Plt ___
___ 05:58AM BLOOD Glucose-96 UreaN-8 Creat-1.3* Na-140
K-3.9 Cl-104 HCO3-23 AnGap-17
___ 05:24AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
Urine culture: no growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Donepezil 10 mg PO QHS
5. Simvastatin 20 mg PO QPM
6. TraZODone 25 mg PO Q6H:PRN agitation
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Donepezil 10 mg PO QHS
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. TraZODone 25 mg PO Q6H:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hematuria with urinary retention
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with dementia with worsening confusion, admitted
with leukocytosis, cultures negative, please assess for aspiration// ?
aspiration
IMPRESSION:
No previous images. There is hyperexpansion of the lungs suggesting
underlying chronic pulmonary disease. Enlargement of the cardiac silhouette
with left ventricular prominence and dense calcification in the descending
thoracic aorta.
No evidence of pulmonary vascular congestion, pleural effusion, or acute focal
pneumonia.
Surgical clips are seen in the region of the left breast.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with dementia, mild, but significantly worse
memory just over past month, accompanied by poor po intake. assess for
subacute strokes that may explain his decline.// ? subacute stroke
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.5 s, 21.5 cm; CTDIvol = 51.9 mGy (Head) DLP =
1,120.5 mGy-cm.
Total DLP (Head) = 1,121 mGy-cm.
COMPARISON: None available
FINDINGS:
There is no evidence of acute cortical infarction,definite evidence of
hemorrhage,edema,or mass. There is small chronic left cerebellar infarct.
There is probably benign prevascular space in the inferior left basal ganglia,
less likely chronic lacunar infarct. There are moderate to severe chronic
small vessel ischemic changes, which decreased sensitivity in detecting deep
white matter subacute infarcts. There is advanced generalized brain
parenchymal atrophy. There are 2 linear foci involving anterior bilateral
frontal lobes seen on same image series 2 image 12, 1 on each side, which
likely represent an artifact, foci of cortical laminar necrosis related to
subacute to chronic infarcts or small focus of parenchymal hemorrhages very
unlikely. There is no adjacent brain edema or gyral expansion to suggest
underlying process.
There is no evidence of fracture. There is near complete opacification of the
left frontal sinus, with chronic osteitis, consistent with mild acute on
chronic inflammation. There is chronic osteitis and partial opacification of
the visualized very top of left maxillary sinus. Otherwise, the visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
There is no definite evidence of subacute infarcts, although, underlying
moderate to severe chronic small vessel ischemic changes decreased sensitivity
of this exam in detecting deep white matter subacute infarcts.
There is generalized brain parenchymal atrophy.
2 subtle foci of abnormality in the anterior frontal lobes are likely an
artifact.
Paranasal sinus disease, as above.
Radiology Report
EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS
INDICATION: ___ year old man with dementia, HTN, and hypothyroid found to have
right hip pain with difficulty ambulating. In setting of dementia he is
unable to provide history of trauma. Imaging to assess for fracture ___
lesion.// ?hip fracture or bone lesion
TECHNIQUE: Pelvis single view, bilateral hips two views each side.
COMPARISON: None
FINDINGS:
There is moderate degenerative arthritis of bilateral hips with hypertrophic
changes, chondrocalcinosis, and mild joint space narrowing, more prominent on
the left. There are no fractures. There are extensive arterial
calcifications. Benign inter sub petit right iliac bone. Partially seen are
degenerative changes in the lumbar spine.
IMPRESSION:
No fractures.
Degenerative changes bilateral hips.
No worrisome osseous lesions.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hematuria
Diagnosed with Hematuria, unspecified, Acute kidney failure, unspecified
temperature: 98.3
heartrate: 68.0
resprate: 16.0
o2sat: 97.0
sbp: 143.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ h/o hematuria & urinary retention h/o remote prostate
cancer, dementia with significant decline 1 month ago, HTN, and
hypothyroid was sent from ___ for hematuria noted to have poor
PO appetite and 25 pound weight loss over the past
month.
1. Hematuria with urinary retention h/o prostate cancer
-Foley placed in ED for retention (?obstruction from
mass/prostate vs blood clots) with mention of pyuria however
urine culture without growth and antibiotics not continued.
Attempted to remove foley ___ but patient developed bleeding
and significant pain and it was left in. Foley was removed
successfully ___, and patient able to void without retention
noted on bladder scans.
-Hematuria is concerning for malignancy especially in setting of
h/o prostate cancer; sister notes prostate cancer about ___ years
ago treated with radiation ?+/-surgery, but I do not have access
to these records. He had seen a urologist before, but she does
not believe he sees one anymore. At this point sister (HCP)
with support from her daughter-in-law who is a hematologist they
would like to see urology and likely pursue cystoscopy. This
will be done as an outpatient.
2. ___ vs CKD
Due to paucity of records unknown baseline Creatinine.
Creatinine stable at 1.3.
3. Microcytic anemia
-Due to paucity of records unknown baseline hemoglobin with
differential of anemia including hematuria vs underlying
malignancy. This can be followed outpatient.
4. Dementia
___ Alzheimer's with dementia workup unrevealing for
alternative cause. Discussed progression of dementia with
sister who is very familiar with this as their sister died with
dementia. At this time will continue with supportive care, which
includes 1:1 assistance with feeding. Continue donepezil.
Patient's sister ___ ___ is HCP and I also
spoke with her daughter-in-law ___ ___
(hematologist) to help make goals of care decision. Need to
continue to address code status as patient currently full code.
5. Malnutrition, poor PO intake
Appreciate recommendations from SLP and nutrition. Patient is
having difficulty eating in setting of dementia essentially
forgetting to chew & swallow. With prompting and 1:1 assistance
he does fine with regular foods; in setting of absent back
molars he can be changed to ground meat consistency if he has
further difficulty. Continue ensure enlive TID with meals and
magic cup BID.
Chronic Medical Problems
1. HTN: continue amlodipine and metoprolol
2. HLD: holding simvastatin (due to interaction with amlodipine
and risk>benefit given age and comorbidities)
3. Hypothyroid h/o Grave's: continue levothyroxine
>30 minutes spent on discharge planning |